“Three-quarters,” said Farmer. “Come on, Alex. Those are crimes against property.”
“There is twenty-five percent should be in jail for life,” said Goldfarb.
“No. Ten percent,” said Farmer. “You think I’m naïve.”
“You are not naïve,” said Goldfarb. “You see the whole situation. You just don’t accept that—”
“People aren’t nice.”
“No! Bad people. You are not naïve. You can just disregard things which are unpleasant, and that is why you are not scientific. You disregard reality.”
“But you still like me,” said Farmer.
“Of course I like you!” said Goldfarb.
Farmer really did love storms, even if he rarely said so without adding that they usually afflicted the poor more than others. He had said he wished for a blizzard in Moscow. He had gotten just a snowfall. We walked back to the hotel on slippery sidewalks in the cold, cold night, Farmer with his red scarf over his nose, his glasses fogging up. We had put away three bottles of wine. I said, “You look thinner than when we started out.”
“It’s been a long trip,” he said.
“Well, that was interesting,” I said. “I like Alex.”
“I’m glad. Alex is great. I was really mad at him when he first said that about prisoners, the first time I met him.” He did a Russian accent: “They are bad people but epeedeemeeologically eempoortant.”
I rehearsed their closing argument, Farmer’s whittling down the number who he thought should be in prison. If it had gone on, I thought, he might have gotten down to one percent, or zero.
“Do you think I’m crazy?” Farmer asked.
“No. But some of those prisoners have done terrible things.”
“I know,” he said. “And I believe in historical accuracy.”
“But you forgive everyone.”
“I guess I do. Do you think that’s crazy?”
“No,” I said. “But I think it’s a fight you can’t win.”
“That’s all right. I’m prepared for defeat.”
“But there are the small victories,” I said.
“Yes! And I love them!”
My thoughts were a bit hazy, my voice, I sensed, a little slurred. I began to pose a hypothetical question, which I thought expressed great insight into his peripatetic life. “You’re a great guy,” I said, putting a hand on his shoulder. “But without your clinical practice—”
He interrupted. He said, “I wouldn’t be anything.”
CHAPTER 24
In July 2000 the Gates Foundation gave Partners In Health and a cohort of other organizations $45 million to wipe out MDR-TB in Peru, virtually everything Jim Kim had asked for. William Foege, the foundation’s science adviser, the man behind the grant, liked to tell this story: Several groups all interested in the same international health problem had fought with one another for years, until he went to their leaders and said, “Gates wants to do a grant for this, but only one grant,” whereupon it took about two hours for the warring factions to make peace. Jim borrowed this strategy. He included as partners some potential and former adversaries, such as WHO’s tuberculosis branch. The money would be funneled through Harvard Medical School, but PIH would run the actual treatment program in Peru.
The grant would last five years. In that time, Jim figured, they’d have to treat about two thousand chronic MDR patients and cure at least 80 percent. Peru would then have control of the dread disease, and the world would have proof that countrywide control was possible and would also have the techniques and low-cost tools for accomplishing it. If all went well, that is. Partners In Health and its allies would have to convert a community health project into a national one. Inevitably there would be problems in this “scaling-up.” “At times I feel like my head’s going to explode,” Jim told me, but he had no doubt they’d succeed.
Neither did Farmer, though he fretted some, as he did over every project, partly in this case so that Jim wouldn’t get distracted but would go on fretting, too. Farmer had other, ancillary worries. When the people who had long supported PIH read about the grant—the news made the front page of The Boston Globe—would they think the charity didn’t need their money anymore? Would some think PIH had sold its soul? In speeches to old allies and donors, Farmer began to talk about “unusual alliances.” To illustrate his point, he’d show a slide of assembled photographs, in which, for instance, Fidel Castro appeared alongside the Pope, Bill Gates, and the pop singer Britney Spears. The audience would laugh, and Farmer would say, speaking of the Gates grant, “It’s a wonderful thing for us, but it’s very focused on our project in Peru. And we’re focused on the problems of the poor. On accidents, machete wounds, burns, eclampsia. Imagine asking a foundation to support that. They’d say, ‘We have a procedure and it doesn’t include those things, as you’ll see when you look in volume three of our grants manual.’ We’ve had a run of luck, but it’s not going to solve the problems of our sister organizations—in Chiapas, in Roxbury, in Haiti.” Then he’d pause and, smiling down from the lectern at the old friends of PIH, intone, “So you are not dismissed.”
In fact, large foundations tended to finance narrowly focused campaigns against well-publicized diseases. None was likely to be interested in simply paying the bills, year after year, for a comprehensive health care system like Zanmi Lasante. Individual donations and Tom White’s dwindling fortune still were the main support for Cange, where nonetheless Farmer went on expanding his anti-AIDS campaign. Soon he had about 250 patients taking antiretrovirals there. He had grafted AIDS treatment onto Zanmi Lasante’s TB program, of directly observed therapy and monthly stipends, and the early results were good—many stories of lives restored and orphanings prevented. But the waiting list of dying patients grew longer every day, and funding for antiretroviral drugs was still scarce. Though the woman he’d met in Cuba worked ardently on his behalf, UNAIDS turned down the application he’d submitted, on the grounds that his AIDS-treatment program failed to meet “sustainability criteria.” That is, the drugs were too expensive for Haitians to buy for themselves in any conceivable future. Farmer got the same answer everywhere, and when he approached the drug companies, looking for donations or at least reduced prices, they suggested he go to the same agencies and foundations that had deemed his program nonsustainable because of high drug prices. He was getting by for now. Soros’s foundation, which had a branch in Haiti, put up some money. Tom White made a special gift. And PIH sold its headquarters building in Cambridge, and Farmer spent most of the proceeds on drugs for treating AIDS in Cange.
Friends at Harvard Medical School had already adopted PIH and given it a second name, the Program in Infectious Disease and Social Change. (Later, not to be outdone, the Brigham would create a special division and another alias for PIH, the Division of Social Medicine and Health Inequalities.) Meanwhile, Farmer had talked the medical school into providing headquarters space for the entire growing crew, in portions of a pair of old brick buildings on Huntington Avenue, charming and warrenlike inside.
Every time I went there, I’d find that offices had moved, and soon I couldn’t keep all the new names and faces straight. Just the other day, it seemed, the typical PIH-er had been a volunteer who took on chores such as finding Paul’s lost luggage, then went back to analyzing epidemiological data. To meet a deadline, they’d stay all night, sleeping in shifts on a couch in the old headquarters. Now the staff included professionals in administration and information technology and grant writing, and they didn’t know the PIH lingo, let alone the customs. For years Ophelia had served as the presiding spirit at headquarters, the person everyone could count on to be fair and sympathetic and, usually, temperate. Now she was trying to accommodate newcomers, trying, as Jim put it, to “normalize” the experience of working as a PIH-er: it was okay to have children, to go home some days at five o’clock, to take a vacation.
On one visit, in a new employee’s office, I saw a sign taped to a wall which read, “If
Paul is the model, we’re golden.” When you looked closely, though, you saw that the word golden was written on a strip of paper. Lift up the strip and you saw that the original read, “If Paul is the model, we’re fucked.” This was a direct quote from Jim, a characteristically emphatic phrase, which sounded harsher than it was. Jim meant it as a warning to the many young PIH-ers who imagined, as many had and many would, that the right thing to do with their lives was to imitate Paul. To Jim, attempts at imitation would put the emphasis where it didn’t belong. The goal was to improve the lives of others, not oneself. “It’s not about the quest for personal efficacy,” as Paul himself liked to say. Besides, frank imitations would fail. What PIH-ers should take from Paul wasn’t a manual for their own lives but the proofs he’d created that seemingly intractable problems could be solved. “Paul has created technical solutions to help the rest of us get to decency, a road map to decency that we can all follow without trying to imitate him,” Jim told me, explaining the message on the wall. “Paul is a model of what should be done. He’s not a model for how it has to be done. Let’s celebrate him. Let’s make sure people are inspired by him. But we can’t say anybody should or could be just like him.” He added, “Because if the poor have to wait for a lot of people like Paul to come along before they get good health care, they are totally fucked.”
Farmer didn’t disagree. I was with him one time when he was stewing over an e-mail from a student who had written that he believed in Paul’s cause but didn’t think he could do what Paul did. Farmer said aloud to his computer screen, “I didn’t say you should do what I do. I just said these things should be done!” Then he framed a mild reply.
The change in PIH wasn’t total. Some of the old quirkiness survived. In the old days Paul would return from a trip to Haiti, arrive at the one-room office, and the next thing Ophelia knew there would be suitcases spilling all over the floor, and everyone would be running off in various directions, doing chores for his next project. Then he’d be gone again, and she would look at Jim and say, “What just happened?” Paul still created what Ophelia called “little hurricanes.” I came to the new offices once, hours after Paul had left town, and found Jim laughing, shaking his head. He had just looked in on the women who were now trying to manage Paul’s schedule and travel and correspondence, and had found them in tears. Not because Paul had been cruel to them—“He’s never mean,” Ophelia had said, and this was true in my experience. This was a case of nervous exhaustion, a case, Jim said, of “decompressing from Paul.”
The old frugality of PIH endured. The charity still used only about 5 percent of donations to administer itself, and all the rest on services to patients. Some months after they received the Gates grant, Farmer wrote an open letter to the organization. In it, he worried that PIH might be losing its way “morally.” This because, among other things, some employees expected to be paid for working extra hours. He wrote, “One can never work overtime for the poor. We’re only scrambling to make up for our deficiencies.” Ophelia agreed in principle. She wasn’t going to let PIH get bound and gagged by other institutions’ rules. But she would allow some compromises, because PIH’s connections to other institutions meant they could treat more patients. Their formal connection to Harvard obliged them to pay overtime to some of their lowest-salaried employees. Ophelia, who managed such matters, was following those rules. She simply didn’t tell Paul.
About 20 people had worked at Partners In Health headquarters in Boston when I had first visited, late in 1999. Now there were 50, and another 10 in Roxbury. The numbers in Haiti had grown to about 400, and to 120 in Peru, and they were about to inherit 15 employees in Russia, because on top of everything else, PIH had expanded to Siberia.
This didn’t happen by plan. It might not have happened at all if Alex Goldfarb hadn’t involved himself in some mysterious relationship with the exiled Russian oligarch Boris Berezovsky. According to one published version of the story, a former KGB agent claimed he’d been ordered to assassinate Berezovsky but had tipped him off instead, allowing Berezovsky to flee Russia with his Swiss bankbooks. Later the KGB agent himself escaped, to Turkey. And then Goldfarb did Berezovsky a favor by helping the KGB agent get to London. Meanwhile, the current Russian government claimed to have a legitimate legal case against the former KGB agent, and the authorities were furious at Goldfarb. So was Soros’s foundation, for putting their TB project in political jeopardy. A new director was needed anyway, because Goldfarb couldn’t very well work in Russia now. He was quoted in a paper called The Russia Journal as saying, “Being a sane person, I would not go to Russia for a couple of weeks, at least. I’m not a fool.”
After a flurry of e-mails, the foundation asked PIH to take over their project in the Siberian oblast of Tomsk. This was the site of the pilot project of pilot projects in the effort to stanch the Russian TB epidemic, the project that would show the way to controlling, in the prisons and the towns and cities, both drug-susceptible TB and MDR. “Tomsk has to work,” Goldfarb had told me in Moscow. On that sentiment, Paul and Jim agreed. The project in Tomsk was vital. Jim was eager to add it on, even though he was already in charge of Peru and involved in the Boston projects. Paul worried. Partners In Health was stretched already. If they tried to do too much and projects faltered, there would be no end of people pointing out the failures, saying they’d shown that MDR and AIDS could not be treated in impoverished settings. But Paul agreed to take on Tomsk, provided that his role be mostly clinical, and that Jim assume the managerial chores and most of the diplomacy. Jim said he’d get to work right away, but he still hadn’t gone to Russia when, about a month later, he and Paul and Ophelia went out to dinner together at a restaurant in Cambridge. I went along.
“You said yes to Russia,” Paul told Jim, not long after we sat down. His voice had the intensity of yelling, not the full volume, but it was rising. “You fucking promised me! And you’re not gonna go.”
Jim protested. He had planned to travel to Tomsk this month, but it turned out he had to attend TB meetings in Bellagio, at the Rockefeller Foundation’s estate on Lake Como. The meetings were crucial, Jim said.
“I don’t care!” Farmer said. His neck had turned red. The veins in it stood out. “Fuck Bellagio. Bellagio, fucking Bellagio. You need to go to Moscow and Tomsk, where there’s real work. You need to do some real work in Moscow. Then you can go to Bellagio and do your Harvard crap.” He turned to Ophelia. “All I’m saying, Min, is that he has to go. I said, ‘You won’t do it, I know it, you’re going to cancel, you won’t go.’ Now he’s talking about … Bellagio. The heck with Bellagio. Lago di Como. Look, I would like to go to my grave never having gone to Bellagio.” Paul said that Jim had gone to Moscow only once in his life, and hadn’t even left the airport.
“That’s not true,” said Jim in a quiet voice.
“You went into town for the Bolshoi crap.”
“I would have,” said Jim, “but they canceled the performance.”
Farmer turned to Ophelia. “They canceled the Bolshoi, Min. But he would have gone.” He went on, “I’m going to go to Russia a couple of times this year, but I would like to focus on the things Jim told me I could focus on.” He turned to Jim. “What were they? You tell her.”
Jim smiled. “The Bolshoi and …”
“And dressage,” said Ophelia.
Farmer didn’t laugh. He said to Ophelia, “I’m asking him to limit the damage in Russia.”
She said softly, “He knows that, P.J.”
“Well?” said Farmer. “Force him to do it.”
Jim turned to Ophelia. “He’s trying to irritate me enough …”
“I know,” she said.
The times had grown rare when all three were in the same place at the same time, but even the nostalgic talk didn’t sound nostalgic tonight.
Ophelia said to Farmer, “Jim used to pick you up at the airport.”
“Used to,” said Paul.
“You never picked me up,” said Jim.
“That’s what he always said,” Farmer announced to the table. “He said, ‘You never pick me up.’ And you were coming from Los Angeles? Sorry.”
“You never did,” said Jim.
“Where were you coming from?” said Paul. “You were coming from Los Angeles, or Chicago.”
“Yeah, yeah,” said Ophelia wearily.
“I was coming from Haiti,” said Paul. “I wanted to talk to you about, what did I want to talk to you about? I talked about nothing? I always talked about Haiti.”
“Anyway …,” said Ophelia.
“I’ve made my mistake,” said Paul. “I’ll never do it again. I’ll never ask you to pick me up again.”
“That’s not the point,” said Jim. “The point is, you never picked me up.”
Ophelia told me that Paul never let himself lose his temper when it might jeopardize PIH’s missions. She didn’t mind that he lost it sometimes in front of her and Jim. That was safe, she thought, and also probably good for Paul’s psyche. After the dinner she said to me, “You think that was bad? What he was doing to Jim was nothing. On a scale of one to ten, that was about a five.” I guessed she was right. As Paul and Jim walked out the door, I saw Paul put his arm around Jim’s shoulder and Jim put his arm around Paul’s, and I could see they were laughing. A few weeks later, Jim flew to Siberia. I went with him.
It was four hours by plane from Moscow, in a Russian-made Tupolov 154, which had a scarred wooden toilet seat in its rest room that I figured could not be older than the plane itself. Tomsk was a city of about half a million, partially filled with Soviet constructions of steel and glass and cement block, and also with old wooden houses heaved into lopsidedness by many long winters, houses covered with fantastically ornate window casings and cornices. The city had several huge public buildings, classically porticoed. Tomsk’s university was Siberia’s oldest. The city had a reputable medical school and factories that made lightbulbs and matches. It had electrified trolley cars, and five competing Internet providers. But Tomsk Air had gone bankrupt, and the airport, formerly the Airport of the Workers, received not the previous forty-seven flights daily but only a handful. And the water, because of incipient flooding, wasn’t safe to drink when we got there. Tomsk was a place where the war monuments were well-tended, and residential backyards and front yards were full of junk, poking out of the snow. We stayed in a hotel with overheated rooms and sloping floors. I had a strange dream the first night there, of a landscape full of monuments in which derelict automobiles sat on top of marble pillars.