Back in Haiti, he had established a piece of private language for our month of travel. Discussing malaria with me, he’d explained there were four types, only one of which, falciparum, was often fatal. “So which one do you suppose Haiti has?” he asked. Then he added, “But it’s not drug-resistant, the way it is in Africa.” He smiled, and then, adapting his favorite line from the movie Caddyshack, he said, “So we got dat goin’ for us.” Then he pointed at me, and I soon learned this meant I was supposed to utter the next line in the movie: “Which is nice.” After I got the hang of this call and response, I enjoyed it. And I must confess I felt a certain pleasure now, at the airport café, in knowing what he meant by “an H of G.”
He went on writing his letter. I looked around. The airport, Charles de Gaulle, has an angular, steel-and-glass simplicity, which struck me just then as frighteningly complex, which made me feel projected into a future I didn’t understand. I thought of its duty-free shop, where one could buy first-class pâté, confit d’oie, grand cru wines. “You started that letter on a hike in rural Haiti,” I mused aloud, thinking now of those arid highlands, of medieval peasant huts, donkey ambulances. “It seems like another world.”
Farmer looked up, smiling, and in a chirpy-sounding voice he said, “But that feeling has the disadvantage of being …” He paused a beat. “Wrong.”
“Well,” I retorted, “it depends on how you look at it.”
“No, it doesn’t,” he replied, in a very pleasant voice. “The polite thing to say would be, ‘You’re right. It’s a parallel universe. There really is no relation between the massive accumulation of wealth in one part of the world and abject misery in another.’ ” He looked at me. He’d made me laugh. “You know I’m being funny about something serious,” he said.
One time I listened to Farmer give a talk on HIV to a class at the Harvard School of Public Health, and in the midst of reciting data, he mentioned the Haitian phrase “looking for life, destroying life.” Then he explained, “It’s an expression Haitians use if a poor woman selling mangoes falls off a truck and dies.” I felt as if for that moment I could see a little way into his mind. It seemed like a place of hyperconnectivity. At moments like that, I thought that what he wanted was to erase both time and geography, connecting all parts of his life and tying them instrumentally to a world in which he saw intimate, inescapable connections between the gleaming corporate offices of Paris and New York and a legless man lying on the mud floor of a hut in the remotest part of remote Haiti. Of all the world’s errors, he seemed to feel, the most fundamental was the “erasing” of people, the “hiding away” of suffering. “My big struggle is how people can not care, erase, not remember.”
I had wondered if there was room in his philosophy for anyone but the world’s poor and people who campaigned on behalf of the poor. One day on an airplane, he confided to me that he thought of all our fellow passengers as patients. An attendant’s voice had said over the intercom, “Is there a doctor onboard?” He’d gotten up at once and ministered to a middle-aged, evidently middle-class American man who, as it turned out, wasn’t having a heart attack. Back in his seat afterward, Farmer said this happened to him about once in every eighteen flights. I had the impression that he wouldn’t have minded if it happened every flight.
Embracing a continuity and interconnectedness that excluded no one seemed like another of Farmer’s peculiar liberties. It came with a lot of burdens, of course, but it also freed him from the efforts that many people make to find refuge and distinction from their pasts, and from the mass of their fellow human beings.
CHAPTER 23
The World Bank was planning a loan to try to stanch the TB epidemic in Russia. Farmer was going to Moscow, for the fifth time now, to work on the terms of the loan. On the airplane, he explained the history of this mission.
About two years back, Howard Hiatt had sent him to the Open Society Institute, George Soros’s foundation, to search for new money to sustain the project in Peru. The OSI declined to get involved, but said in a letter that they understood the importance of PIH’s project because they were doing similar work in Russia. They described this in some detail.
Farmer remembered that he read the letter on his way to a meeting and that it made him stop on the sidewalk: “Holy shit!” He was already aware that Soros had put up about $13 million for TB pilot projects in Russia, but he hadn’t known the details until then. They would use only the DOTS strategy. They would treat all patients for nonresistant TB, and for those who didn’t get better, they’d provide hospice care to ease their deaths. But the collapse of the Soviet Union had created ideal ingredients both for a very large epidemic and for rampant drug resistance within it: a failing TB control system had led to many uncompleted therapies; rising crime had led to overcrowded prisons.
With Hiatt’s blessing, Farmer wrote the foundation’s director a courtly two-page letter, explaining that their project was bound to fail. He ended up in George Soros’s Manhattan office. Farmer made his case. Then Soros ordered that the director of his Russian TB program, Alex Goldfarb, the Russian émigré and microbiologist, be contacted at once. Soros yelled at Goldfarb for a while over the phone. Then he asked Farmer to help fix the Russian pilot projects.
Farmer wavered briefly. At the time, he still had to travel fairly often to Peru. Russia would mean even more days and weeks away from Haiti, a place much more afflicted by TB and every other disease. Still, PIH could legitimately use some of Soros’s money to pay salaries. Besides, Russia’s epidemic was ravaging its prisons, and prisoners were part of PIH’s special constituency—the Gospels said so; you could look it up, in Matthew 25. And Russia might represent the kind of opportunity Paul and Jim had hoped for when they’d taken on Peru, a chance to affect health policy toward the poor on a global scale. Russia bordered twelve other countries these days, and those countries bordered some of the world’s wealthiest. “It’s much more difficult to make arguments for equity in a place like Haiti, which can be so easily hidden away. But it’s pretty hard to hide Russia,” Farmer reasoned. Russian TB might show the world the consequences of neglecting the health of poor people everywhere, of neglecting Haiti.
So he went on a tour of Siberian prisons with Goldfarb and some other advisers to the Soros Foundation and some Russian officials. Before the trip Goldfarb had referred to Farmer as “the evil enemy from the north.” They returned from Siberia as friends. By then Goldfarb understood Farmer better. At one point he’d asked Farmer what fee he charged for his services, and Farmer had said, “Alex, you idiot, what’s my fee? I charge a lot for prisoners, POWs, and the destitute sick. And I really ramp it up for refugees.” Mostly, though, what united them was the spectacle they’d witnessed in the Russian gulag.
In most places, prisoners contract TB at higher rates than civilians. In Russia’s prisons, though, the incidence was forty to fifty times higher. Moreover, the majority of sick inmates had strains resistant to at least one drug, while nearly a third in some of the jails had full-fledged MDR. Tuberculosis had become the leading cause of death in the prisons, but not all were dying there. Many inmates were surviving long enough to get released and bring their drug-resistant strains of TB back into civilian society. And when they got out, most of those who were sick didn’t get treated, mainly because Russia’s huge civilian TB control system was itself in shambles.
The situation was dire, but so far the international response had been puny. About a dozen non-Russian organizations were trying to figure out how to control the epidemic. Most had only small amounts to spend—hundreds of thousands of dollars or a million or two. Their projects, some well-managed, all established in the face of great obstacles, had shown what they hadn’t intended—that DOTS alone not only wouldn’t serve but would amplify the epidemic. In the Russian oblast of Ivanovo, the U.S. Centers for Disease Control and Prevention had knowingly treated MDR patients with drugs they were resistant to and had cured only 5 percent of them. And Farmer predicted—correctly as it wou
ld turn out—that many of that 5 percent would relapse. Even Doctors Without Borders, praised by the Nobel Prize Committee for its work on TB in Russia, had so far hewed to the code of DOTS alone, and had cured only 46 percent of the patients they’d treated in Prison Colony 33 in Kemerovo. “Managerial successes, clinical failures” Farmer called these efforts in a paper.
The epidemic he’d seen in Siberia’s prisons was worse than anything he’d seen in Peru, and in some respects anything he’d witnessed in Haiti. So when they got back to Moscow from their tour of the gulag, he and Goldfarb held a press conference to spread the dire news, but they did so on the day when, in Washington, the special prosecutor released his report on the Monica Lewinsky scandal. Only a handful of reporters came.
Farmer and Goldfarb flew on to New York, for an “emergency meeting” with Soros. For Farmer, meetings with the man were often refreshing. Farmer once made a quick estimate of what it would cost to control TB throughout the world—about $5 billion, he thought. He mentioned this figure to public health people, and they said such a sum could never be raised. When Soros saw the estimate, though, he said, “Is that all? You only need that?” In New York, Farmer and Goldfarb asked Soros to put up more money at once for treating TB in Russia. Soros said that would just delay the international response. Instead, among other things, he arranged a meeting at the White House, his friend Hillary Clinton presiding. Farmer and Goldfarb wrote the talking points for Soros and critiqued the ones prepared for the First Lady.
The upshot wasn’t all Farmer thought it should be. He’d hoped for large grants from foundations and wealthy nations. Instead, Hillary Clinton prevailed on the World Bank to look into giving Russia a loan. And the World Bank created something called a mission to Moscow, a group of economists, epidemiologists, and public health experts who would work out the details of a loan.
Predictably, Farmer got more and more deeply involved, bringing the rest of PIH along. The whole crew labored on a report commissioned by Soros—and in seven months turned out a book with 177 pages of text, 115 pages of appendices, 976 references, with chapters describing the problem of MDR in Russia, Azerbaijan, Peru, and South Africa, and a final chapter about how to create a proper treatment program. It stirred up some press, and WHO endorsed the volume by contributing an introduction. Farmer also agreed to serve as the chief but unpaid consultant on TB in Russian prisons for the World Bank’s mission to Moscow—unpaid at his insistence; he deplored some of the bank’s policies; Soros was taking care of his expenses.
We arrived in Moscow late in the afternoon. Most of the passengers got up from their seats before the plane had reached the gate, and the flight attendant pleaded uselessly over the intercom, “Would you please remain seated?”
Farmer looked around the cabin. “I have a soft spot for the Rooskies. They get up when they feel like it. Of course, the Russians have been used like furniture for the last four hundred years. No wonder they want to stand.”
Farmer believed, obviously, in the importance of intentions and the power of will, but also in revelation, in “signs.” Today, it seemed to me, not all omens were good. Inside Moscow’s main airport, which had all the charm of a warehouse, we filled out the wrong entry forms, and for the first time since I’d been traveling with Farmer, I witnessed his friendliness fail with a stranger. He smiled at the grim-faced, uniformed woman at customs and said, “Sorry. Next time I’ll learn Russian.”
“Next time fill out the English form,” she snarled.
But she let us pass. Farmer said, with sympathy, not irony, “That’s all right. After all, she’s an employee of a defeated superpower.”
Outside, the afternoon sun was an orange sliver on an icy horizon.
In the morning, outside our hotel, the air steamed from mouths—of pedestrians, of grates in the street. From the hotel’s front windows, you could look across a broad avenue at the Kremlin Palace, crenellated towers on high walls, all in perfect repair, stretching out of sight. Beyond, I could see the onion-topped towers of St. Basil’s Cathedral. Farmer had said he thought it one of the world’s most beautiful buildings, but marred by the fact that it had been built to celebrate Ivan the Terrible’s bloody victory over the Tartars. Erasing history, he liked to say, always served the interests of power. Anyway, I knew I wouldn’t be going to the cathedral with him. In Moscow, we were going to practice his kind of tourism, a transit one could make in any major city in the world. We—Farmer and I and Alex Goldfarb, who had flown in from New York—were going to visit a prison.
Moscow’s Central Prison, Matrosskaya Tishina, was the city’s largest jail, designated a sizo, a detention center. The building was immense, though I couldn’t grasp its actual dimensions because of the complexity of turnings, through doorways where you had to duck your head, and climbings, up ancient metal staircases, and hikes, down corridors that made me think of abandoned subway tunnels, with some sort of yellow fiberboard slapped haphazardly on the walls. “In summer,” Farmer whispered to me, “the air-conditioning doesn’t work so well.” He added, “The last few years I’ve been doing my practicum in comparative penology.” We passed through various climate zones, from warm to cold to warm again, and regions of odor, some of food, others hard to place—it seemed better not to know.
“Don’t get lost,” a prison official said. “This is not a good place to get lost.”
We passed a file of inmates, all dressed in baggy pants, in ragged coats and caps, gray faces in dim light; one had the crookedest nose I’d ever seen. Then we reached the prison hospital. “Think of Cuba,” Farmer whispered to me. “Look at this shitty place.” Our guides were doctors in olive drab uniforms and public health officials in olive drab uniforms, and they themselves deplored the conditions. They opened the door to a cell reserved for patients with AIDS. “There are fewer than in the usual cells,” one of the female doctors said.
“How many?”
“Only fifty in this room.”
Farmer went in first, followed by a translator. It was a dingy gray chamber, smaller than many American living rooms, full of double-decker beds, laundry hanging from clotheslines. Most of the men were young. Their faces looked gray, but perhaps that was because of the dimness of the light. In a moment Farmer was shaking hands with them, touching arms and shoulders, and in another moment loud voices all around him were competing to air grievances. “You should go to the courts and stand up for the rights of the AIDS-infected on trial,” said one of the inmates.
“Tell him I do that in the U.S.,” Farmer said to the translator. “But since I’m not a Russian citizen …”
One prisoner, older than the rest, evidently something like a spokesman, declared that he had merely been a witness to the killing of a man, but because he had AIDS he got a sentence of five years. The actual killer, who was tried with him, got only three. “And when I get out, I will cut his head off,” he said. Everyone, prisoners and doctors, laughed, a deafening sound in the cramped cell. Farmer made a note—“AIDS patients get longer prison sentences?”—and said he’d pass it on to the World Bank’s AIDS specialist.
He thanked the prisoners. The spokesman said, “I wish you would come more often.”
“I would like to.”
We left the cell of the fifty AIDS patients, and the door clanged shut behind us. That sound, of heavy old metal on metal, echoing down a dimly lit hallway. I couldn’t see the end of the hallway. I couldn’t hear the end of the echo. “Ever imagine what it would be like to hear that sound on the other side of the door?” I asked Farmer.
“Every time,” he said.
It really wasn’t hard to imagine—making the kind of mistake that would end in a cell inside this place. In Russia just now, a young man could get thrown in jail for stealing a loaf of bread or a bottle of vodka and, because the criminal justice system was clogged, languish in a detention center for a year or even four years before his case came to trial. While waiting or while serving his sentence, he’d probably get infected with TB—it was
estimated that about 80 percent of all Russian prisoners had bacilli in their bodies. Once infected, he stood a better than average chance of coming down with the active disease—because of poor hygiene, inadequate nutrition, the prevalence of other illnesses in jail. And the underfinanced prison medical service didn’t have the equipment or drugs to achieve a respectable cure rate even among the inmates with drug-susceptible TB. A young prisoner could contract susceptible TB and, through inadequate treatment, end up with MDR. Or, increasingly likely, he could catch a strain of MDR directly from another inmate and die from it before he even got sentenced for stealing his loaf of bread.
We were led on another twisty passage, down a winding metal stair, then through what looked like a medieval dungeon. We passed an old man pushing a cart. It had big metal cans on it. An enormous ladle stuck out of one. He stopped at a hole in a cell door. A face appeared at the hole. “The food’s pretty good actually,” Farmer said to me. “Salty.” High praise from the doctor with high blood pressure.
We arrived at the TB department. “The doctors are overworked and have almost no protection,” a prison official said. “The X-ray equipment it is exhausted. There are not enough drugs for the patients that we have. We do not have laboratory support from Moscow.”
They weren’t sure how many prisoners had drug-resistant strains. Certainly more than a handful. Of 100,000 inmates sick with TB, perhaps 30,000 had MDR. Last October, Farmer had appeared on the TV show 60 Minutes to talk about the epidemic in Russia and its former republics. “We’re going to have to declare this a global public health emergency,” he had said.
“How much time is there before this gets really out of hand?” the TV host had asked.
“I think it’s already out of hand,” Farmer had replied.
We lingered in the hall of the TB department. One of the Russian doctors said, “We get no information from the other institutions where the prisoners come from. This is a division of the railway station. Fifty percent are not from Moscow.”