Tomsk and the huge territory around it had a severe MDR-TB problem but one that seemed likely to be brought under control, in part thanks to Alex Goldfarb’s efforts. However, because of Goldfarb’s other efforts on behalf of the KGB agent, rumors were swirling around everyone who worked in the TB project, rumors that they were really spies against the motherland, part of a nefarious plot in which the patients were serving as fronts. To quell local suspicions, arrangements had been made for the vice minister of justice, who was in charge of Russia’s prisons, to come to Tomsk and endorse the project and PIH’s new role in it, in front of TV cameras. The vice minister had agreed to do this, a Russian general told me, because of his friendship with Farmer. A banquet was planned. Farmer was supposed to attend. He got stuck in Paris, however. His latest assistant in Boston, a young woman, had made a mistake. He couldn’t get his visa until the following day. So Jim had to go it alone.
The banquet took place in what seemed like a VIP safe house, a small, luxurious private hotel tucked into a corner of a vast, gray concrete apartment and shopping complex still under construction, a part of Tomsk called, for some strange reason, Paris. The event was important. DOTS-plus would have no chance of succeeding in Russia without the ardent help of the generals who ran the prisons. Nor would the project in Tomsk, if the generals didn’t trust Jim, whom they’d never met before. But a stiff formality prevailed for the first two hours or so, in spite of dozens of toasts and half a dozen bottles of vodka consumed.
The vice minister and ten big-handed Russian generals and colonels in heavy olive drab uniforms sat on one side of the assembled tables. On the other side sat the foreigners and the Russian doctors now working for PIH. The division seemed unbreachable. However, Jim had spied a TV equipped for karaoke, and as the fish course was being served I heard him whisper, “I’m gonna do it.” He stood, raising his shot glass. “I’m a terrible singer, but in my culture, Korean culture, if you respect someone and you have a deep affection and admiration for the people you’re with, you should embarrass yourself by singing for them. So I will sing for you.”
Jim belted out “My Way.” The TV orchestra accompanied him, the words scrolled across the TV screen, and then the TV got stuck, and Jim went on alone, hitting a few sour notes. Everyone clapped, and then a member of MERLIN, a British international health organization also working in Tomsk, got up and sang “Summertime,” and then a two-star general ordered up a Russian song from the TV, a lively tune, the generals and the vice minister, Yuri Ivanovich Kalinin, clapping out the rhythm. Then one of the generals asked one of the Soros doctors to dance, and the Tomsk civilian TB chief, a man as large as a mature black bear, danced with a young woman from MERLIN, and Jim sang “La Bamba,” and another general followed with another Russian song, while images of Broadway and bathing beauties on Caribbean beaches rolled across the TV screen. And then something rather magical happened. Without warning, and without mechanical aids, Vice Minister Kalinin himself began to sing, in a deep baritone so clear it sounded trained, a lovely, slow, and mournful-sounding ballad, and all the generals and colonels joined in. The jailers of Russia together in song. I swear it was possible, given the hour, the quantity of vodka drunk, to enjoy that spectacle of comradeship without so much as a thought about what they had all been comrades in.
I don’t think I merely imagined that the farewell speeches were tinged with affection. “Dear friends,” one general began. “I really mean you are my friends.” Bottoms up again. Another general rose. “We have gathered around this beautiful table. All the people in the world have the same emotions. We just want to do something good for this earth.” He raised his glass. “That we finish this work according to the DOTS program.” He pointed to the vodka bottle in front of him. “Directly observed therapy.”
Outside, snowflakes lit the air. The generals drove away with a police escort, little sedans with whirling blue lights on their roofs. Jim watched them depart, his smile like the snowflakes in the dark. “The night of the singing gulagmeisters. We’re not going to see that again soon.”
The next morning Jim left, and Paul arrived. He stayed only one day, which he spent examining MDR patients and giving various press conferences with the vice minister. There was another banquet that night, a smaller, quieter affair in the same strange, small hotel. At one point Vice Minister Kalinin raised his glass and said, “To Alex Goldfarb. He worked very hard and was sincere.”
Farmer raised his glass. “To Alexander Davidovich. May he stay out of trouble.”
Halfway through the meal, a man with tousled hair who looked like a figure in one of Goya’s paintings of drunks—skin flushed, eyes squinty—wandered into the room. The interpreter leaned over to Farmer and explained that this man was a local oligarch, part owner of this place and also of Siberian gas and oil fields. The oligarch, meanwhile, was weaving his way to the head of the table. He squared his shoulders and declared, “Dear guests, I would like to say a few words. Energy is the force of life. Tomsk Oblast has oil, coal.” He sucked at his teeth and corrected himself. “Tomsk doesn’t have any coal, and we have to use more and more of the gas. We will be able to supply the energy needs of several oblasts.”
“Bravo!” cried one of the generals.
“To the energy program!” cried Farmer.
“The moral of the story is that energy is the secret to everything in life,” said the drunken interloper. “Thank you very much for coming to Siberia.”
“I love Siberia!” Farmer declared from down at the other end of the table.
The oligarch lurched away. For a moment, it seemed he was leaving, but he’d only gone to get a chair. He lugged it back to the table and sat down on it heavily. “I do apologize for breaking into your life.” He cleared his throat. “I have helped a lot already. I invest a lot in culture and medicine for the city.”
Other conversations resumed around the man. He seemed to be talking to himself. “What’s he saying?” I asked the interpreter.
“Now he’s speculating about why the Russian life is so hard.”
Finally, he wandered away, and soon the farewell toasts and the good-byes began, the party moving out to the lobby. Farmer was dressed in a furry Russian hat and was saying good-bye for the third time to the vice minister. “I was very upset I wasn’t here yesterday, but now I see that it’s all right. We are waiting for your marching orders.” He was lifting a military salute to the minister when, from a side door, the oligarch of oil and gas reappeared, naked except for a towel wrapped around his waist. He headed toward the billiard room, lurching past the vice minister, who smiled and shrugged and went back to saying good-bye. Moments later the hotel manager, a buxom woman, fully dressed and in high heels and looking greatly alarmed, came running through the lobby, pursuing the oligarch. I couldn’t make out what was going on, and neither could Farmer, but, smiling gleefully, he turned and watched the chase.
We flew to Paris the next day. When we were settled in the chilly cabin of the Tupolov 154—“Has it come to this? Have we reached that age?” said Farmer as we spread blankets on our laps—I asked him a technical question about TB control, reciting an opinion I’d heard. “Would that be accurate?”
“Every account is partial.” He smiled over at me. “Except mine.” He went on, “I have to say, Rooskies are my kind of people.”
“I’ve heard you say that before,” I remarked.
“PIH-ers accuse me of saying it about everyone. But it comes in handy in my line of work. To like people.” He made up a list of types who shouldn’t be doctors. “Curmudgeons, sadists …”
Then he began the dismount of our short stay in Tomsk. The essence was a brief discourse on drugs. Low-cost second-line antibiotics would soon be on their way to Russia, but at the moment various snafus had delayed their arrival. Other organizations, now intent on treating MDR in Russia, were still waiting for the inexpensive drugs. Farmer and Kim, by contrast, had gone to Tom White and asked for $150,000, and bought enough drugs, at high prices
, to start treating a few dozen MDR patients in Tomsk right away. Why do that, why spend $150,000 now on drugs for thirty-seven patients if, by waiting a while, they could spend the same amount and buy drugs to treat a hundred? Well, Farmer said, project managers could afford to wait for low prices, but not all patients could. “It’s going to take resources to stop this epidemic,” he said. “And if you want to use money to buy the resources, fine. I don’t care what you use. Use cowrie shells.”
Soon Farmer went to sleep. He napped most of the way to the Ural Mountains, and I tried to digest what he’d said about money. It occurred to me that PIH would probably always be in some kind of financial jeopardy, because it was constitutionally impossible for Farmer and Kim to sit on resources—to wait for lower drug prices while MDR killed Russian prisoners, to save for an endowment for Zanmi Lasante while Haitian peasants died of AIDS. Their approach, especially toward money, was completely impractical, it seemed to me, and yet it appeared to be working.
Farmer was traveling more than ever. To familiar sites such as Peru and Siberia (including one trip all the way from Haiti to Tomsk for a two-hour meeting, which he considered a great success) and to Paris (where he’d agreed to give a prestigious lecture series, so as to spend more time with Didi and Catherine) and to New York (where he testified on behalf of a Haitian with AIDS who was at risk of being deported). He went to dozens of American and Canadian universities and colleges, preaching his O for the P gospel, and to South Africa, where he debated a World Bank official at an international AIDS conference. (Africans must learn to curb their sexual appetites, the banker remarked, and Farmer replied, “I want to talk about other bankers, not the World Bankers, but bankers in general. My suspicion is they’re not getting a lot of sex, because they spend a lot of time screwing the poor.”) He went to Guatemala to see some bodies dug up. (Partners In Health had found a donor to pay for a mental health project there: the disinterment and proper reburial of Mayan Indians who had been slaughtered by the Guatemalan army and dumped in mass graves.) One time, not long after he’d taken a fall in Cange and broken both an arm and his tailbone, he flew all the way around the world, bound for Asia on TB business.
I kept in touch with him by e-mail—he wrote almost every day—and sometimes in person. Once, in the city of San Cristóbal, in Chiapas, I stood with Ophelia and watched him from a little distance as he strode down a narrow sidewalk, a thin, long-legged white man in a black suit, weaving his way past brown-faced women in colorful Indian shawls hawking trinkets. Ophelia thought he looked like the mysterious figure at the start of a Graham Greene novel. Who was that man in the rumpled suit, and where was he going in such a hurry? I wasn’t sure that the real answers would have been plausible enough for the novelist’s purpose. The aim of that trip was to persuade PIH’s tiny Mexican outpost to expand their public health efforts in the troubled, impoverished villages of Chiapas—an effort which, if successful, would oblige Farmer and Ophelia and Jim to do more fund-raising. And the reason he was hurrying through the streets of San Cristóbal at that moment was to get back to our hotel in time for a scheduled telephone interview with a radio station in Los Angeles, which wanted his views on AIDS.
He returned to Boston, as always, for monthlong tours of service at the Brigham. I followed him on a couple of memorable cases. A migrant worker from Mexico has been shipped to Boston from a hospital in Maine, suffering from Fournier’s gangrene—a malady first described in France in the nineteenth century as “lightning gangrene of the penis.” The surgeons’ debridement of the dead tissue has left the man’s waist and groin looking like a side of butchered beef, and some on the house staff think it’s time to consider hospice care. But Farmer says cheerily, “He’s going to walk out of here,” and about a month later the man does. A graduate student, a young man, has arrived at the Brigham very near death. Farmer is called in and at once corrects the house staff’s diagnosis. It’s toxic shock, he says, and adjusts the medications. Two weeks after that the young man lies in his bed, delirious with fever, shaking so hard that from the doorway to his room I can hear his teeth chatter. The tips of his fingers and toes have turned black. And as I’m staring at him, thinking he won’t make it to morning, I hear Farmer saying to the parents, “The next two weeks won’t be a picnic, but the worst is over. He’s going to walk out of here.”
In tears, the mother says, “We trust you. Thank you so much.” Two weeks later the young man’s father asks if he can’t repay Farmer somehow. Perhaps he can buy him a car?
He’s on call one evening, driving through Boston, when his cell phone rings. “Paul Farmer. Infectious Disease,” he answers. I gather the caller is another doctor, asking advice on a case. Farmer murmurs, “Uh-huh. I see.” Then he asks, “Can you tell me what species of monkey it was?”
Service at the Brigham was so gratifying to him that he sometimes wondered aloud if he should give it up. Every day brought interesting cases and the pleasure of working in a hospital staffed and equipped to the highest current standards in medicine, where he could order a brain biopsy and not have to raise money to pay for it. He got medically recharged during his stopovers in Boston, but they were hardly a rest. Noting that his suit now looked like something he’d found in a trash barrel, but knowing she’d never get him to a department store, Ophelia gave his assistants a tape measure. But during most of a month he never stood still long enough for them to use it, and he left town in the same clothes.
E-mail wasn’t always an enlightening means of following Farmer on his travels, because he sometimes neglected to say where he was. But one knew that most of his trips began and ended in Haiti. Some of his friends and allies continued to think he should go there far less often, and spend most of his time deploying medical troops on worldwide campaigns. Howard Hiatt felt that way more and more insistently, until he visited Zanmi Lasante. It was Dr. Hiatt’s first sight of the place. When he got back to Boston, he wrote, in an editorial for The New York Times: “I have just returned from a health center in a country at the bottom of the economic heap. … HIV infections are controlled as effectively in an area of Haiti as in Boston, Massachusetts. More than that, medical care there is delivered with skill and caring comparable to that seen in a Boston teaching hospital.” Zanmi Lasante had moved him more deeply than anything he’d ever seen before, Hiatt told me. He said that what Paul had done in Cange had to be “replicated.” And he said he intended to spend whatever time he had left on earth doing all he could to see that it was.
Replicability and sustainability—in the case of Cange, these terms had the same meaning perhaps. In Jim Kim’s view, Zanmi Lasante wouldn’t survive without the support of some large foundation or international agency, and it wouldn’t get that support unless it was seen as something like a laboratory for the world, not just as a marvelous anomaly. At times this kind of talk made Farmer testy. “It’s galling,” he told me in the winter of 2002. “It should be enough to humbly serve the poor.” Within a few months, though, replicating Zanmi Lasante had become his main preoccupation.
Ever since the advent of effective treatments for AIDS, in the latter 1990s, there had been debate on how and where to use the antiretroviral drugs. The argument had a grand scale and great complexity, but in fundamental ways it resembled the debates about MDR treatment—most experts saying that only prevention, not treatment, was feasible in places like Haiti and sub-Saharan Africa; others, and especially groups like ACT UP, calling the failure to treat not just immoral but also foolish, since it was clear that prevention alone would not halt the growing pandemic. To Farmer, the distinction between prevention and treatment was artificial, created, he felt, as an excuse for inaction. He had long since weighed in, in speeches and books and in dozens of journal articles. Then, in August 2001, he published an article in the British medical journal The Lancet describing the treatment and prevention program in Cange. At once PIH began receiving requests for advice and information—at one point I counted nearly one hundred. They came from ministries of
health and consultants and charities from every continent. The Harvard “Consensus Statement,” an argument for worldwide treatment, which 140 of the faculty signed, cited the project in Cange. The new chief of WHO’s TB division praised it in a letter to The New York Times. Meanwhile, the economist Jeffrey Sachs was dispersing the Lancet article far and wide.
Sachs had visited Zanmi Lasante himself, and he’d had much the same reaction as Howard Hiatt. Sachs wrote to me,
Paul’s work (and his concept of high-quality medical care for the poor) has had a huge effect. I was able to use the example of his work in many key fora around the world in the past few years, with the U.S. Congress, the WHO Commission on Macroeconomics and Health, the White House, the U.S. Treasury, United Nations Secretary General Kofi Annan, etc. When I worked with the Secretary General to help launch the Global Fund to Fight AIDS, Tuberculosis and Malaria, Paul’s work was a key example.
“It’s embarrassing that piddly little projects like ours should serve as exemplars,” Farmer told me. “It’s only because other people haven’t been doing their jobs.” It did seem like a case of gross disproportion in cause and effect. In the world, about 40 million people were infected with HIV, and a program that was treating only hundreds of those in rural Haiti had somehow acquired great weight. But Zanmi Lasante’s program was in fact unique, at least at the time of Farmer’s Lancet article. Other small AIDS-treatment and -prevention programs were under way in poor countries, but Zanmi Lasante’s was the only one in an impoverished rural area that chose its patients solely on medical grounds and not on their ability to pay, the only one that provided expert care and treatment for free.