Mountains Beyond Mountains

by Tracy Kidder

  Farmer asked how long it took for a tuberculous inmate to get from here to a Siberian prison.

  “About a month. They are sent to way stations. There is no way to maintain treatment en route.”

  Farmer turned to Goldfarb and said in a low voice, “These prisoner transfers are going to be nightmares.”

  We went into another cell, this one filled with TB patients, a cell much the same as the last but a little more crowded and humid—the humidity that comes from many pairs of lungs exhaling. Several men were coughing, each distinctively, I thought—a Chaliapin bass, a baritone, a tenor. Farmer stood beside a bed, his arm resting on the mattress of an upper berth. “You look good,” he said to one of the men. “Anybody coughing up blood?”

  “No.”

  “So pretty much people are getting better?”

  “It’s not worse,” said a prisoner.

  He asked them where they came from. Grozny, Volga, Baku. “Tell them I’ve been to Baku,” Farmer said to the translator. “And it’s better to be here. Tell them I’ve been to Colony Three.”

  A young man sitting on an upper berth said, “I saw you in Colony Three. You were with a woman.”

  “Yes, I was there with a woman!” Farmer exclaimed. He reached out his hand and shook with the man. “It’s nice to see you again.”

  It was time to leave. “Good luck,” said Farmer through the translator. “Tell them I hope everybody gets better.”

  We headed back toward the prison office. “I like these prison medical people,” Farmer said to me. “They’re trying.” He turned to the translator. “Tell Ludmilla”—she was one of the Russian doctors—“I’ve met some extremely dedicated prison doctors.” He had singled out Ludmilla because she’d told him a story about an Italian human rights activist who had inspected the prison and accused her of mistreating AIDS patients by keeping them isolated from the other inmates. Farmer had said, “In a setting where there’s a lot of TB? Not to isolate them would be a violation of human rights!”

  Farmer spoke softly to me as we walked along. “They have seven hundred hospital beds in this place, and about five hundred are filled with TB patients. That’s a clue, just a clue that there might be a problem.” On top of drug resistance—one of the doctors had told Farmer—the incidence of syphilis was rising. Alarming, because rising syphilis announces the imminence of AIDS, which would grossly magnify the TB epidemic. “It’s gonna be a fucking disaster,” Farmer was saying, as the hosts ushered us into the central office, a mustard-colored chamber.

  Now the crude conference table there was laid with a feast. Farmer declared, “Oh, thank you! Just what I like!” He murmured to me, “I was afraid of this. I hate vodka.” But he sat down and knocked it back with expertly feigned pleasure, just as he did in Haiti when eating from the fifth food group. Toasts were offered, and countertoasts. After a while, Farmer’s grew lengthy.

  “I have been working in Haiti for almost twenty years, ever since I was a young chap, and some years ago I was asked by the state of Massachusetts to be a TB commissioner, and I said, ‘What the hell do we do?’ I was in Haiti and I had a couple of MDR-TB patients and I took sputums and I brought them to Boston. And I took them into the lab and I wrote, ‘Paul Farmer, State TB Commissioner.’ I wanted them to process my samples from Haiti and they did and never asked any questions, so I did it more and more and then I did it with sputums from Peru, and of course, eventually they asked me why. I said, ‘Massachusetts is a great state, it has a big TB lab, lots of TB doctors, lots of TB nurses, lots of TB lab specialists. It lacks only one thing. Tuberculosis.’ ”

  The chief of the Russian doctors—a colonel—laughed. A woman doctor said gravely, “We have lots of TB and no labs.”

  More toasts, more vodka. The colonel reached in his pocket, began to take a pack of cigarettes from it, then paused and asked Farmer, “Is America a democracy?”

  Paul’s face grew serious. “I think whenever a people has enormous resources, it is easy for them to call themselves democratic. I think of myself more as a physician than as an American. Ludmilla and I, we belong to the nation of those who care for the sick. Americans are lazy democrats, and it is my belief, as someone who shares the same nationality as Ludmilla, I think that the rich can always call themselves democratic, but the sick people are not among the rich.” I thought he was done, but he was only pausing for the interpreter to catch up. “Look, I’m very proud to be an American. I have many opportunities because I’m American. I can travel freely throughout the world, I can start projects, but that’s called privilege, not democracy.”

  As Farmer had talked, the colonel’s face had begun showing signs of exertion. Now he let his laughter out. He said, “But I only wanted to know if you would permit me to smoke a cigarette.”

  Goldfarb made a face. “Paul. He wanted to know if he could smoke, and you gave heem a speech on socialism and democracy.”

  “But the speech was marvelous,” said the colonel, smiling at Farmer, who seemed on the verge of falling asleep.

  Goldfarb turned to the colonel. “Tomorrow Paul will represent your interests at the World Bank.”

  Farmer shook himself alert. “The only thing wrong, I don’t think it should be a loan. But for the international community of healers it will be a good thing. I pray”—he put his hands together in a steeple—“that it will go well.”

  In the world of TB control, experts were still wrangling about MDR treatment, a fray in which journal articles were the principal weapons. But, as Howard Hiatt said, Farmer and Kim had shown that MDR could be treated, and indeed cost-effectively. Partly thanks to the example of their work in Peru, the World Bank shared a consensus: the loan should be used to treat all strains of TB in Russia; that is, should be used for both DOTS and DOTS-plus campaigns. The Russian officials agreed; in fact, this had long been their essential position. But opinions still divided on how the loan would be allocated. And the mixture of players involved in the discussions seemed combustible, like the nations of Europe before World War I—a stew of World Bank consultants with substantial résumés, some with egos to match, combined with Russian colonels and generals and former apparatchiks and old TB warriors, members of a defeated empire, on the lookout for condescension.

  Alex Goldfarb was himself part of the complexity.

  One night over cocktails, one of the members of the World Bank team had said to Farmer, “I like Alex, but please keep him away from the meetings.” Goldfarb was Farmer’s main ally in the negotiations, Farmer representing the bank on the problem of TB among prisoners and Goldfarb representing the Russian Ministry of Justice, which ran the prisons. For Farmer and Goldfarb, the objective this week was to make sure that the prisons got a fair share of the loan. Farmer had told me that he had an additional task: “I have to keep Alex in check.”

  Most mornings and evenings during the week in Moscow, Alex came to our hotel to discuss strategy. He looked professorial, with his beard, his slight stoop, his tweed and corduroy. “I am very respected biochemist,” he told me.

  Farmer turned to me. “He discovered one of the genes that creates resistance.” He smiled at Alex. “Otherwise he’s not much.”

  Then Farmer began to give Alex a rundown of the meetings so far.

  Alex listened for a time, then said, speaking of Farmer’s chief antagonist on the World Bank team, “Who is this asshole? I am so amazed by him. Such arrogance and such ignorance. Why don’t I put this story in Izvestia tomorrow?”

  “I knew you would say that,” said Farmer. He looked at me. “You laugh, but he does things like that.”

  Alex went on, “The World Bank brought here an expert with a turban from India, in this terrible snow, and he doesn’t know anything about Russia, and he’s feenished. These people don’t know what is going on with this country.”

  Farmer tried to continue. Alex broke in. Farmer said, “Let me finish.”

  Alex said, “Let me tell you something. The people whom you are meeting with are totally
insigneeficant.”

  “Alex, would you let me fucking finish?” said Farmer. Across the hotel dining room, heads turned. Farmer lowered his voice. “You don’t have to keep interrupting me. You change our proposal the way you want it. My job is to tell you what they’re going to gripe about.”

  “Insigneeficant persons,” said Alex.

  There were many divisions attached to these meetings, according to Alex. Here was the political landscape, according to him. The foreigners hammering out the details of the loan harbored many animosities. For instance, the World Health Organization bureaucrats stationed in Moscow resented the intrusion on their turf of nongovernmental organizations, such as PIH and Soros’s foundation, which itself, according to Alex, contained competing factions, because Soros liked to create competition inside his own organizations. In addition, some of these WHO people were Polish, not Russian, and between the two nationalities old hatreds still endured.

  Alex related all this with, I thought, a certain relish. Then he said, “But this is insigneeficant.” What mattered, first of all, was the Russian split, between the Ministry of Health and the Ministry of Justice. The Ministry of Health, in charge of the civilian sector, wanted overall control of the loan. Not mainly, Alex said, in order to deal with TB but in order to prop up their crumbling system. There were also shadowy alliances between the Ministry of Health and Russian drug companies, which would not get to supply the vast quantities of TB drugs required if price and quality were the criteria. Moreover, the Ministry of Health bureaucrats felt insulted by many of the internationalists—among others, by Alex, as Farmer pointed out. Alex had called them clowns and worse.

  As for the Ministry of Justice, Alex went on, its motives probably weren’t pure, but its intentions were correct. Nearly half of all TB cases and most of the drug-resistant ones languished in the prisons. And the prisons were playing the role of what Alex called “an epidemiological pump,” spreading TB among prisoners, then sending them back to civilian society. “This pump is replaced every three years. So the best way to clean society is to purify the prisons, just like you clean oil filter in your car.”

  Farmer agreed with all this and felt, in addition, that prisoners deserved attention first. “The point is you’re exposing prisoners to higher risk, so it’s wrong not to treat them first.” He believed that Justice sincerely wanted to cure the tuberculous prisoners. Why wouldn’t they? The prison epidemic threatened their own personnel, indeed their own empire. He felt they were sincere, in part because Justice had given him free access to all sorts of confidential documents. But at the meeting today, the consensus on the World Bank team had seemed to be that Justice—the prisoners—would get only 20 percent of the loan. It was on the question of how to change this view, how to get Justice 50 percent of the loan, that Farmer and Alex divided.

  Farmer sympathized with the Ministry of Health. He had courted the old TB warriors among them, and many liked him. Diplomacy and data and personal charm, he seemed to say, could win over all sides, and unite all factions against the bacillus, their common enemy after all.

  In response to this sort of talk, Alex said, “Paul. You are so naïve.” It was power and money that would prevail, as always. For the moment, he would let Farmer do things his way. “But there is Plan B. Actually, I like Plan B. We fail. The prisons get shortchanged. All the money goes to the Ministry of Health. Then we raise hell. Then we have a perfect weapon to go raise private money.”

  Farmer said, “But you won’t do that yet, because I’ll feel I wasted a whole year in the World Bank offices.”

  “Why did you go there?” said Alex.

  “Why did I go there?” said Farmer, raising his voice. “Because you told me to!”

  Alex chuckled. “Of course I did.”

  For a time, I thought Goldfarb might be right, that the odds were long against Farmer’s getting the prisoners half the loan. Farmer had told me on the plane to Moscow that he was tired of the World Bank meetings and the arguments, in conference rooms that grew increasingly airless, where there were no patients, his thoughts straying back to Cange: When the next meningitis victim came in, would one of the doctors, in his absence, do a spinal tap? And he seemed physically exhausted. Our first morning in Moscow, at breakfast—for him, a euphemism for coffee—he told me, “I’m still biologically deranged.” He wore his third and last shirt. One of the buttons was missing. His black suit looked as if he’d slept in it. Actually, he hadn’t slept. “But I did answer all four hundred and thirteen e-mails,” he said, momentarily buoyant.

  One quadrant of his hair stuck up like a rooster’s, and his face and neck were red, probably because in his mind he was already arguing. Among the e-mails he’d dealt with last night, he’d found one that quoted a member of the World Bank team as saying, “It’s ridiculous and too expensive, this proposal for the prisons. It’s ridiculous.” Now Farmer himself said, over his coffee, “The battle is joined. But this is a ten-year program. This is a very long process. Ten years. I think I should be nonconflictual at least for a day. I’m trying to talk to myself. I’m trying to keep myself from slugging the guy.”

  He went on, “The prisoners are dying. They’ll go on dying.” Then he looked at his watch. He was nearly late for the morning meeting. He hurried off, pulling on his overcoat. The cord of his computer trailed out of his briefcase, dragging along on the carpet behind him. “Sir,” said the doorman, picking up Farmer’s gloves.

  “Oh, thank you!” said Farmer and eagerly asked, “Is it going to snow?” as the doorman held the door and Farmer hunched his shoulders against the blast of January Moscow air.

  In the evening he looked somewhat restored. The head of the Russian negotiating team had held aloft a translated version of an article Farmer had written called “Resurgent TB in Russia” and had said, “You are the only one who understands TB in Russia.” Then the negotiators had wrangled over the preliminary plan Farmer presented for the prisons, especially over the part that would give tuberculous prisoners extra food. Was extra food necessary for cures? Some didn’t think so. “We had a food fight,” Farmer said. But he hadn’t let himself get involved in any others.

  And snow was predicted for Moscow. The news cheered him. He’d always loved a storm. “I want a blizzard!” he said.

  Farmer had told me that playing the game of international health politics didn’t come easily to him. But he was good at it, clearly, and as the days in Moscow wore on, his smiles and his vigor returned and with them, somehow, the illusion of a stylishly dressed man.

  Some members of the negotiating team continued to insist that extra food for the prisoners wasn’t cost-effective, but then one of the negotiators took Farmer aside and suggested that he sneak food into the budget by calling it vitamins. This worked. In the end, the World Bank team agreed that the prisoners would get about half the loan. Just now, the first installment was projected at $30 million, and the figure was bound to increase by another $100 million or so. But there might not be a loan. The Ministry of Health was bound to be displeased with their share. Still, Farmer had accomplished his main, intermediate goals, and had kept Goldfarb from executing his “Plan B.”

  Up in his hotel room, Farmer said, “It was a total success. I can’t help but be excited. So, Alex, are you happy?”

  “Yes,” said Alex. “I’m always ambeevalent, though. It means I have to deal with this thirty million. Keep them from stealing it.”

  “They’re all your friends,” said Farmer. “So one of them steals for vodka and another steals for his girlfriend. Big deal.”

  Farmer was perched on a windowsill. Papers covered the chairs in his room. He pointed at a teetering pile of PIH stationery that an assistant had brought from Boston. “Alex, do you see the difference between your life and mine? Those are thank-you letters for twenty-five-dollar contributions to PIH.”

  “You do that stuff? How do you make mailing lists? Buy them?”

  “Oh, come on. It’s been built up over thirteen years. Y
ou get to write, Dear George Soros, thank you for the twelve million dollars.” Farmer took up a sheaf of thank-you notes still to do and said, “I get to write to, let’s see, a friend of my grandmother’s, a student, a left-wing economist, an historian, a secretary in my department, an administrator in my department, a pediatrician.” The recitation seemed to raise his spirits still higher. I think he was bragging, actually.

  Alex’s views on Farmer interested me. “Paul is so fragile,” he told me privately. “He is so thin. He is like Chekhov. Sentimentality fuels him rather than otherwise. But I have never met an efficient individual who didn’t claim to be sentimental or working for a higher cause. Even in business, certainly in international work.”

  For his part, Farmer had said of Alex, “Only a mother could love him. I do love him. I really do. And this whole thing in Russia is going to work. You know why? Because he loves me.”

  They seemed to have the sort of friendship that thrives on argument, and they had plenty of fodder. Take a subject like Cuba, for instance. About its health statistics, Alex said, “I think Comrade Fidel is very good at establishing discipline, so his public health must be very disciplined. I think Comrade Beria would fix the problem in Siberian prisons. Just shoot a few people.”

  Or take a subject like the Russian prisoners. Farmer said, “If the reason most of them are locked up is degeneracy, then how come the number of prisoners rises so much during times of great social and economic crisis or change?”

  Alex saw this matter differently. At dinner one night, he remarked, “Prisoners. They are not nice people. They are epeedeemeeologically eempoortant.”

  “Our big split,” said Farmer.

  “I should take that back,” Goldfarb said. “About half of the people should not be in jail.”