Summary

This chapter examines Farmer's and Kidder's trip to Moscow. This is Farmer's fifth trip trying to obtain a loan from the World Bank for the Russian TB program. On the airplane, he explains the history of the mission. Two years before, Howard Hiatt had sent him to George Soros' foundation to search for new money for Peru. This foundation declined to become involved, but described to him the similar work they were doing in Russia. The letter they sent explains the details of the $13 million Soros had committed to it. They had insisted on a DOTS only program with hospice care for those who didn't respond to it. Then, the collapse of the Soviet Union had been an ideal situation for the increase of TB and rising crime had led to over-crowded prisons where the TB flourished. Farmer told Soros his program was doomed to fail. Soros then yelled at Alex Goldfarb over the phone and asked Farmer for his help. At first, Farmer didn't want to give up his time in Haiti, but because prisoners were special constituents of PIH, he decided to get involved, especially because it was a way to show the consequences of neglecting health everywhere.

So Farmer went on a tour of the Siberian prisons with Goldfarb and realized, just as he had believed, that prisoners contract TB at higher rates than civilians, and in Russian prisons, it was 40 to 50 per times higher. It had become the leading cause of death there. What's worse, many of the TB patients left prison before they were cured and took it back to the civilian population. The situation was dire and the Russian response puny. It was worse than anything he had seen in Peru or Haiti. Unfortunately, when he and Goldfarb held a press conference to announce their findings, it was the same day that the Special Prosecutor released his report on the Monica Lewinsky scandal, so few reporters showed up. As a result, Farmer and Goldfarb flew to New York to speak with Soros. Farmer told the man that it would take $5 billion to control TB throughout the world, but he only wanted Soros to put up more money for Russia. Soros felt that would delay the international response, so using his friendship with Hilary Clinton, he went about getting a loan from the World Bank. Even though, Farmer was against the idea of a loan, he became more and more involved. Now he is on his fifth trip, hoping this time the money will become available.

Farmer, Kidder, and Alex Goldfarb visit Moscow's Central Prison, Mastrosskaya Tishina, an immense building where you don't want to get lost. Farmer, as prisoners come into view, points out how much worse it is even than Haiti. They enter a cell filled with fifty AIDS patients, and Farmer talks through an interpreter and is thanked for his visit. After this visit, Kidder explains, one can understand the problem more clearly. Too many people are being thrown into prison for minor crimes, really adding to the spread of TB throughout the country. Furthermore, the TB department in the prison has overworked doctors, almost no protection, exhausted X-ray equipment, not enough drugs for the number of patients, and no support from Moscow. Of 100,000 inmates, probably 30,000 had TB. Farmer even took the problem to the American TV program, Sixty Minutes where he's asked how soon the problem will get out of hand. Farmer soberly replies that it already is.

Then, they are taken to a cell filled with TB patients and amazingly Farmer meets people who have met him before. He also really likes the medical personnel, because they are really trying. Farmer tells Kidder as they walk along that they have 700 beds in this prison and 500 of them are filled with TB patients. Add to that a rise in syphilis, which indicates there will be a rise in AIDS. It's gonna be a disaster, Farmer says. When they sit down to eat, Farmer tells an interesting story: he had been named the TB commissioner for the state of Massachusetts and so every time he needed lab resources, he went back there, because Massachusetts has a lot of TB labs, lots of TB doctors, lots of TB nurses, lots of TB lab specialists. What Massachusetts doesn't have is TB. That's just the opposite in Russia.

The next day, they go to speak to representatives of the World Bank, who believe the loan should be used to treat all strains of TB, that is, both DOTS and DOTS-plus. The division comes in how the money should be allocated. Farmer knows he has to keep Alex in check, because he can be offensive in how he views all the bureaucrats, so he brings him first to their hotel room where they go over strategy. Alex believes that the people they will meet with are totally insignificant. They all are involved in turf wars: WHO, the World Bank, the Soros Foundation, and even PIH. Alex thinks that what matters is the Russian split between the Ministry of Health, which deals with all Russians, and the Ministry of Justice, which deals with the prisons. There are too many shadowy connections in the Ministry of Health, which he thinks wants the money to prop up their crumbling system. The Ministry of Justice may not be pure, but its intentions are correct. They know the prisons are an epidemiological pump, spreading TB among the prisoners and then releasing them into the general population to further spread the disease. Purifying the prisons will clean society. Unfortunately, the World Bank is inclined to give them only 20% of the money while both Farmer and Goldfarb want 50%. Alex feels they'll fail in their request, so he's ready with Plan B: fail at getting most of the money and resort to raising hell to get the attention of private money.

Farmer must convince the World Bank that they need 50% of the loan not only for medicine, but also for better conditions in the prisons, including increased amounts of food for the sick. The bank argues that it isn't cost-efficient, but then privately tells Farmer to call it vitamins in the proposal, and it will go through. In the end, the World Bank agreed that the Ministry of Justice will receive half the money.

Farmer and Alex love each other and are fast friends, but they argue incessantly, especially over prisoners. Alex sees them as just bad people who are merely epidemiologically important. To Farmer, they are all people in need, albeit with about 10% who are every bad. He asks Kidder later of he thinks he is crazy to feel that way about prisoners. Kidder says no, but points out that some of them have done terrible things. Farmer says he knows that, but he forgives them. Kidder says forgiving everyone is a fight Farmer can't win. To which Farmer replies that he loves the small victories anyway. Kidder says, with his hand on Farmer's shoulder, that the doctor is a great guy, but he wouldn't be anything without his clinical practice.

Notes

The fight in Russia is one which takes Farmer away from the places he really wants to be, but one which is necessary, not just for the patients, but also for the attention of the world on the needs of the poor. He is a clinician at heart, but will be a bureaucrat if he has to.