The World Bank is trying to end the TB epidemic in Russia by funding medical research in the country. On the flight from Paris to Russia, Farmer explains to Kidder that this project has been going on for some 2 years. George Soros, the businessman and philanthropist, had donated 13 million dollars to treating TB in the former Soviet Union. When Farmer found out about this, he immediately wrote a letter to Soros, explaining that these treatments would fail, because they didn’t incorporate drug-resistant TB. Farmer toured Russian prisons where there had been outbreaks of TB. He was amazed that the international response was so minimal. The international community seemed not to care about prison conditions.
At the international level, healthcare is a complex interaction between wealthy donors, bureaucratic organizations like the WHO, and humanitarians like Jim Kim and Paul Farmer. As a result, it’s often easy to lose sight of the patients themselves. This is especially apparent in this chapter, when Farmer concentrates on eradicating TB among Russian prisoners. In most societies, prisons are kept “out of view.” Prisoners’ rights aren’t discussed, and prisoners themselves are seen as second-class citizens who “deserve” any suffering they experience.
Farmer continues to explain the history of the TB project in Russia. Farmer told George Soros that it would take about 5 billion dollars to fight TB throughout the world—an amount that Soros found surprisingly small. He used his political connections to Hillary Clinton, the First Lady at the time, to influence the World Bank to support giving Russia a loan to fight TB. Farmer agreed to be a consultant for the World Bank’s project in Russia.
It’s amusing that George Soros thinks that 5 billion dollars is a small amount for fighting TB. But it’s also a sobering reminder of the immense differences between the wealthy and the poor: men like Soros can have more money than the entire country of Haiti. In Soros’s mind (and probably Farmer’s), then, this is practically a mandate for Soros to devote his life to helping the poor, donating as much of his fortune as he can.
Kidder and Farmer arrive in Russia. Although they drive by Russia’s beautiful towers and churches, they don’t stop to look at any “tourist destinations.” Instead, they visit the central prison of Moscow. Farmer is disgusted with the conditions inside the prison. Inmates with AIDS are quarantined, 50 to a room. One inmate claims that he was sentenced to 5 years in prison simply because he has AIDS. In Russia, Kidder knows, it’s not unusual to be sent to jail for 4 years for stealing a loaf of bread. During this time, inmates contract many dangerous diseases, such as syphilis, AIDS, and TB.
Kidder’s description of a Russian prison is disgusting, frightening, and, above all, morally reprehensible. Most of the people in these prisons simply don’t deserve to be there (though Farmer and Kidder will later have an argument about what portion does deserve to be there), and instead are just the victims of a corrupt system governed by unjust officials. In many ways, the prevalence of AIDS and TB is an apt metaphor for the futility of the prison system: people are sent to prison to be punished, but come out “infected” with crime and fear.
Farmer and Kidder dine with the chief of Russian doctors, along with some of the chief’s colleagues. The chief asks Farmer if America is a democracy, and Farmer answers that Americans are lazy democrats: wealthy Americans live in a democracy, but the poor don’t. He promises to represent the interests of the Russian prison population at the World Bank the next day.
Farmer doesn’t sugarcoat his opinions of the United States. The fact that he’s among Russians, especially, means that he can be as critical of the U.S. as he wants without alienating his listeners. Farmer’s view of the American political system is harsh but unfortunately quite accurate.
Kidder notes that Farmer and Jim Kim have demonstrated that MDR can be treated cost-effectively, meaning that they’re often invited to TB panels in Russia. At the World Bank meetings, which aim to allocate new funding to Russia for wiping out TB in prisons, Farmer speaks alongside his old colleague Alex Goldfarb. Goldfarb, Farmer tells Kidder, is a somewhat unlikable man with an inflated sense of his own intelligence and talent. Nevertheless, Goldfarb is on Farmer’s side. Prior to their meeting with the World Bank, Farmer and Goldfarb review the details of their plan for Russian prisons. Goldfarb wants to treat prisoners immediately, ensuring that dangerous strains of TB aren’t released into the Russian population in the near future. Farmer agrees with this approach. They plan to ask for half the total loan being sent to Russia from the World Bank.
Goldfarb is an important foil for Farmer, even though both are important philanthropists. Where Farmer is charismatic and humble, Goldfarb is argumentative and arrogant. Moreover, Goldfarb is more willing than Farmer to think in cold-blooded, utilitarian terms. Here, for example, he rationalizes prison treatments on the grounds that they could lead to outbreaks in the general Russian population later on. While this isn’t the kind of reasoning that Farmer approves of, we’ve seen him use similar utilitarian strategies to convince American and Peruvian audiences of the efficacy of his TB treatments. Perhaps the difference between Goldfarb and Farmer is that Goldfarb truly believes in efficiency arguments, while Farmer merely uses them strategically.
On the day of the World Bank conference, Farmer dresses in a surprisingly stylish suit, explaining to Kidder that politics is all about the perception of confidence and power. At the conference, the World Bank agrees to allocate about half of its total loan for the prison population. While this isn’t ideal, it’s a success for Farmer, since it means that the prison population will be taken care of for the foreseeable future.
Farmer’s suit is an apt symbol for his pragmatic political engagement. Although he’s most comfortable in ordinary clothes, he’s willing to put on a suit if it’ll help him convince others to fund his healthcare programs. Likewise, he’s willing to temporarily silence his opinions or cater to others’ views if it means helping to save lives.
Kidder watches Farmer and Goldfarb playfully arguing about prison populations. Farmer claims that the vast majority of people in prison don’t deserve to be there. Kidder supports most of Farmer’s argument, though he finds Farmer a little naïve—surely some people in prison deserve to be there. Farmer asks Kidder if Kidder thinks he’s too idealistic, and Kidder admits that sometimes he does. Farmer nods and admits that without his clinical practice, he’d be nothing.
This section—the last of Part Four—is something of a vindication for Kidder’s point of view. Kidder is often skeptical of Farmer’s lofty ambitions and idealist philosophy of right and wrong. Here, Farmer seems to admit that he can be naïve: unlike his friend Jim Kim, his greatest talent isn’t for strategy, but rather for patient care. If Farmer wasn’t so brilliant, successful, and well connected, he would never have achieved such influence, and probably would just remain an especially kind but unknown doctor on a local level.