A REPORTER AT LARGE THE DEVASTATION

Since 1965, life expectancy for Russian men has decreased by nearly six years. And now there is AIDS.

BY MICHAEL SPECTER

he first days of spring are electrify- beds, and they are not filled. The direc- War did a generation ago. “We are on Ting in St. Petersburg. The winters tor, Olga Leonova, is a valiant woman the front line of a war,” she said. “This are hard and dark and long, and when with an impossible job: trying to assure city was under siege by Hitler for years. the light finally returns each year thou- patients that they have a future while We lived through Stalin. We have to sands of people pour onto Nevsky Pros- convincing everyone else that AIDS threat- prevail, and I think, somehow, we will. pekt and into the squares in front of the ens to turn Russia back into the Third We don’t have a choice.’’ Winter Palace and St. Isaac’s Cathedral. World country it was before the Sec- From Tambov, the old Soviet bread- Petersburg has always been more open ond World War. “You can see it getting basket, to the Pacific port city of Vladi- and more openly European than other worse every day,’’ she told me as we vostok, and even in Moscow, which has Russian cities, and the day I arrived this walked around the floor one morning. become a world showcase for conspic- spring was the first on which men in “It’s not just drug addicts now.’’ For years, uous displays of wealth, Russians are shirtsleeves could fling Frisbees across H.I.V. infection in Russia was driven al- dying in numbers and at ages that seem the endless avenues. I settled into one of most exclusively by shared needles. “We impossible to believe. Heart disease, al- the many coffee shops along the Neva are seeing pregnant mothers and peo- cohol consumption, and tuberculosis are River—they are a recent innovation— ple we would never have even tested in epidemic. So is addiction to nicotine.You and noticed something else that was the past.’’ won’t see many pregnant women on the new: a large stack of pamphlets advertis- Dr. Leonova is a middle-aged woman streets; Russia has one of the lowest ing an H.I.V. support group. AIDS is not with chestnut hair and hazel eyes. She peacetime birth rates in modern history. a subject that people talk about much wore stylish striped pants under her lab Long life is one of the central character- in Russia. Even though the epidemic is coat, and her fingernails were painted istics of an advanced society; in Russia, spreading here more rapidly than any- gunmetal gray. She is proud of her ward, men often die too young to collect a pen- where else in the world, there are virtually and enjoyed introducing patients. One sion. In the United States, even during no public-service ads on television about of them, a frail boy with sandy-colored the Great Depression mortality rates it, and the government spends next to hair, had tried to kill himself, because he continued to drop, and the same has been nothing on prevention, treatment, edu- thought he had no hope of living. With true for all other developed countries. cation, or care.This year, the entire bud- drugs provided by the hospice, he would Except Russia. In the past decade, life get for H.I.V.-related matters is a little soon go home. Cases like his are com- expectancy has fallen so drastically that more than five rubles per person, less mon. “Most of our patients have noth- a boy born in Russia today can expect than the cost of a pack of cigarettes. ing when they get here,” Dr. Leonova to live just to the age of fifty-eight, youn- St. Petersburg has been a rare ex- said. “They are dirty and hungry. The ger than if he were born in Bangladesh. ception to what seems like an official first thing we do is take their clothes and No other educated, industrialized nation policy of ignorance and neglect.The city burn them.’’ We had returned to her of- ever has suffered such a prolonged, cata- is responsible for the first program in fice, and while we talked she stood at strophic growth in death rates. Russia that sends buses to deliver in- the window, staring at the birch trees. “I formation—and clean needles—to peo- worry that AIDS will send us over the n 1991, on the day the Soviet Union ple who cannot be reached in other ways. edge—that we will become a country Iwas dissolved, Russia’s population It also pays for health workers to travel too sick to cope. Most people don’t get it. stood at a hundred and forty-nine mil- to schools, hospitals, and even construc- Many of those who do understand have lion. Without the huge wave of immi- tion sites to inform people about their left. My five closest friends now live in gration from the former Soviet republics choices. Condoms are available, and often the United States and Israel. My gen- which followed, the country would have free. Almost two years ago, St. Peters- eration has no children. Husbands are lost nearly a million people each year burg opened the country’s first AIDS hos- dead. And now the young . . . ” Her voice since then. If Russia is lucky, by 2050 pice.There is still only one. Funded with trailed off. Dr. Leonova is an optimist, the population will have fallen by only local money, it sits not far from the city’s but she knows that the illness she en- a third, to a hundred million. That is the Botkin Infectious Disease Hospital, one counters each day is a sign of an even most optimistic government scenario. of the largest such facilities in Russia. larger problem—one that threatens Rus- More realistic predictions suggest that

The hospice is small; it has just sixty sia at least as seriously today as the Cold the number will be closer to seventy-five JOHN RITTER

Even the government’s estimates—which ignore the AIDS epidemic—say that Russia will lose a third of its population by 2050.

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TNY—10/11/04—PAGE 59—133SC.—LIVE OPI ART #R13539 eral AIDS Center, in Moscow, and for two decades he has been the public face of Russia’s efforts to curtail the epi- demic. “They only pay attention when people are dropping dead in the streets. That is going to happen. We can no longer pretend it won’t. It’s just a matter now of how many will die.’’ So far, that message has not sunk in. No senior Kremlin official was willing to discuss AIDS policies with me, because, as one explained, “we don’t have an AIDS policy to discuss. There is no plan, no goals, nothing. It’s not even on our radar.” For most of its history,Russia has de- fined itself physically: as the biggest country on earth and as the place where Europe and Asia come together. Today, however, a nation’s significance is deter- mined more by people than by land. Twenty-five years ago, the population of Russia was a hundred and forty million, •• and that of its neighbor Pakistan was eighty million.Within twenty years, that or eighty million—a little more than tered in Russia, ninety-nine per cent ratio will have reversed itself. If United half the current population. And none have been reported in the past five years, Nations projections hold true, even of these figures allow for the impact of and sixty-five per cent in the past three Yemen will soon have more people than AIDS, which remains, in many ways, un- years. Just at the time when the country Russia.The prevailing view, initially,was recognized and unreckoned with. The will begin to reel under the burden of its that Russia’s sharp decline would be World Bank has estimated that by 2020 shrinking labor force and an increasingly brief—a reflection of the chaos and un- at least five million people will be in- disabled population, it will have to find a certainty confronted in the nineteen- fected with H.I.V.; a more pessimistic, way to cope with millions of AIDS pa- nineties by a new and deeply troubled but equally plausible, figure is fourteen tients, too. society. But the trend actually began de- million. Even without AIDS as a factor, The Russian government has re- cades ago. In an era of antibiotics, molec- working-age people are starting to dis- corded two hundred and ninety-two ular medicine, and universal literacy, the appear. (In the United States, fifteen per thousand people with H.I.V.,but doctors life of the average Russian man is almost cent of men die before they retire; in and AIDS workers estimate that there are six years shorter today than it was in Russia, nearly fifty per cent die.) By at least seven hundred and fifty thou- 1965. Just fifteen years ago, the Soviet 2015, the number of children under the sand. Most epidemiologists, including Union’s status as a superpower was un- age of fifteen will have fallen by a quarter. those from the United Nations AIDS questioned; today, the country is so weak There will be at least five million fewer Program and the World Health Organi- that it is hard to see how it could ever re- people in the workforce. The Russian zation, believe that there may well be gain that status. Ministry of Education projects a thirty- twice that number. Russia’s spotty sys- Russia’s desperation seems to be driv- per-cent drop in school enrollment. Rus- tem of medical accounting makes it im- ing the country in exactly the opposite sian women already bear scarcely more possible to know. People can be treated direction. Last month, in the southern than half the number of children needed only in cities where they are “registered” town of Beslan, Chechen separatists to maintain the current population, and as residents. Official statistics are based killed hundreds of children they had the situation will soon get worse. Be- on cases—whoever walks through the taken hostage at a school. Federal troops tween 2010 and 2025, the number of clinic door. Yet millions of people live il- were given so little support during the women between twenty and twenty- legally in places where they cannot regis- siege that they had to borrow bullets from nine—the primary childbearing years— ter—in Moscow, St. Petersburg, and local civilians.The nation responded with will plummet from eleven and a half other big cities—and so they are not shock, but President Vladimir Putin re- million to six million. Unless there is counted and therefore cannot be helped. sponded cynically: he seized greater sudden new immigration on a gigantic “You can tell a politician that this power for himself. scale, fertility will fall even from today’s country is going to vanish in twenty More than military or political power, anemic level. years if we don’t start dealing with the however, more than guns, revolutions, or A serious AIDS epidemic promises to AIDS epidemic now, but they don’t lis- monarchic decrees, demography is what compound each of these problems im- ten,’’ Vadim Pokrovsky told me. Pok- has often shaped the relationships be- mensely: of all H.I.V. infections regis- rovsky is in charge of the Russian Fed- tween countries. It was, after all, an un-

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TNY—10/11/04—PAGE 60—133SC.—LIVE OPI ART A9821—#2 PAGE TK known epidemic that wiped out a quar- first AIDS death public until late in 1988, steps.They grow exponentially—and, in ter of the Athenian army and at least as and the government seemed at least as the case of AIDS, silently—gathering mo- many of its citizens in 430-429 B.C. interested in the fact that the St. Peters- mentum until, as in countries from Haiti and helped end Athens’ reign as the cap- burg woman who died was a prosti- to South Africa, the epidemic becomes ital of the world. Plague and cholera tute—with many foreign customers—as too forceful to stop. took tens of millions of lives, and played it was in exploring the medical conse- By the end of the eighties, Mikhail an essential role in creating the balance quences of her disease. Soon after her Gorbachev had begun to turn the Soviet of power that existed in Europe for cen- death, the official news agency, TASS,re- Union into a country where people were turies. Even the size of China’s popula- ported that the woman had become a permitted to know the truths that gov- tion can be attributed in part to its relative prostitute in the nineteen-seventies and erned their lives. The 1986 accident at distance from epidemics that devastated had had many African clients. “An au- the nuclear power station in Chernobyl other countries. The economic future of topsy showed that she was four weeks forced the Soviets to introduce some de- a sickly nation with a shrinking popula- pregnant, which indicates that she did gree of honesty into public affairs. After tion cannot be bright. “Russian health not give up sex even at the extreme stage decades of official lies—about genetics, statistics are so bad that we have all run of the disease,” TASS said at the time. the environment, the health of the pop- them, many times,” Nicholas Eberstadt, AIDS was portrayed as the most ruinous ulation, even about which way the rivers a demographer at the American Enter- manifestation of Western decadence. ought to run, and whether it was possi- prise Institute who has written widely The Supreme Soviet had already intro- ble to reverse their course—the Kremlin on Russia’s health crisis, told me. “They duced some of the strictest anti-AIDS had little choice. Pokrovsky told me in never get better. The country just keeps laws in the world, among them a five- 1990 that he felt the country was ready going down—in numbers, in health, and year prison term for infected people who to do what was needed, and, in fact, in its possibilities for the future. It seems knowingly exposed others to the disease. the press had begun to write frequently to get worse every year, and I don’t see The AIDS epidemic started slowly in about H.I.V. While the absolute num- even the slightest suggestion that that Russia—for many years it was hard for ber of infections was low, however, Po- is going to change. Russia, like Africa, foreigners to travel there—and by 1990 krovsky had no illusions that it would I am very sorry to say, is taking a de- the Soviet authorities had registered stay that way if the country did not act tour from the rest of humanity as far as fewer than five hundred cases, including immediately. progress is measured by improving gen- dozens of children accidentally infected Throughout the nineteen-nineties, eral health.’’ by physicians who repeatedly used con- though, AIDS seemed of secondary im- taminated syringes. Like nearly all So- portance. Communism had been re- made my first visit to Moscow in viet (and Russian) health statistics, the placed by a sort of criminal capitalism; I1990, and a few years later I moved number of those infected was no doubt there was a war in Chechnya, and a stock- there. As a medical reporter for much a serious underestimate, based on the market crash and a subsequent economic of the previous decade, I had written questionable system of case reporting. implosion, and also epochal environmen- about the emerging AIDS epidemic in the Yet Russia had been given a rare oppor- tal and health problems. People were United States. In the nineteen-eighties, tunity to learn from the mistakes of oth- dying of stress, of heart attacks. Entire most Americans didn’t want to know ers, and to protect itself from a virus that villages disappeared or turned into drunk about it. Even by the decade’s end, sev- has now infected at least sixty million tanks. Despite the lack of resources, Rus- eral years after Rock Hudson’s death— people worldwide and killed a third of sian physicians are often vigorous, well and not long before Magic Johnson’s in- them—as many as the Black Death. trained, and imaginative. They did their fection set off a second wave of fear and “Because we were not part of the first best to cope with an endless stream of anxiety—the governing sentiment was wave of the epidemic, we were in a priv- accident victims and the results of con- simple: only gay men and drug addicts ileged position, with several years to pre- stant alcohol poisoning.There are better- got AIDS.The rest of us could safely turn pare,” Vadim Pokrovsky told me at the equipped hospitals in Africa, however. our heads and shudder. Ronald Reagan time. Pokrovsky was then the chief of I once stood in an operating room at was President for more than six years the Soviet Center for AIDS Epidemiol- the Semashko Emergency Hospital, in before he used the word in a speech. By ogy. He went on to say that the task of Tula, a city two hundred kilometres from that time, twenty thousand Americans educating the public about AIDS and Moscow, and watched as cancer surgeons had died and more than half a million about sex was formidable. Infectious dis- removed a tumor from a woman’s chest. were infected. It was already clear that eases don’t move forward in measured In the corner of the room, on the floor, H.I.V. would kill tens of millions of sat the mechanism they used to steril- Africans. When I first visited Moscow, ize their instruments: a twenty-five- just as the Soviet Union was lurching dollar hot plate. toward its demise, I assumed that the I went to see Pokrovsky recently, for Russians, with their new freedoms and the first time in years. He was holding openness, would have a problem much a press conference in Moscow for a new like ours. AIDS initiative by the European Union. That assumption was, of course, There are many efforts in Russia now to wrong. The Soviets hadn’t made their focus attention on the epidemic—from

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TNY—10/11/04—PAGE 61—133SC.—LIVE SPOT ART 43705C, PLS INSPECT AND REPORT ON QUALITY the E.U., from the United Nations AIDS AIDS Program has estimated that seventy and say ‘We have a problem and we need Program, from American researchers, thousand people in Russia need such help.’ ” On my way to Moscow, I had and from multinational relief organiza- treatment now, yet only fifteen hundred stopped in Geneva to visit Peter Piot, tions. The only groups that seem to be Russians actually receive the drugs, and an unusually understated and diplomatic missing are Russian. Pokrovsky talked, as almost all of them are in Moscow, by far man, who is in charge of the U.N. AIDS he often has, of an inevitable emergency the richest city. Program. Neither Putin nor any of his that has the potential to destroy the “Our society doesn’t understand what deputies have been willing to meet with country’s already fragile public-health it’s dealing with,” Pokrovsky continued. Piot, something that Presidents and network. He noted that Russia’s demo- “It just isn’t ready. We spend a million Prime Ministers do nearly every week. graphic crisis added special urgency to dollars a year on awareness programs. “No country with this important an AIDS the task. Afterward, there were only a We should be spending seventy million.’’ problem has done so little,’’ Piot said.“It’s couple of desultory questions, and we It isn’t easy to make the case that my biggest nightmare.’’ adjourned to a nearby office. Pokrovsky AIDS requires special attention in a na- John Tedstrom, who is the president is meticulous and soft-spoken, with a tion besieged by other troubles. Coun- of a new organization called Transat- permanently sad smile on his broad face. tries like Kenya, China, and India are lantic Partners Against AIDS, told me His father, Dr. Valentin Pokrovsky, is faced with so many fundamental chal- when we met in Moscow that one of the president of the Russian Academy lenges—starting with the need for clean his goals was to persuade Putin to give of Medical Sciences. His mother is also water and the ability to prevent the most a speech about AIDS. A few days later, a physician. They, too, have sounded basic childhood diseases—that AIDS just the Kremlin asked him to provide some alarms about AIDS,and they,too,have seems like another in a long list of in- paragraphs for the President to include been ignored. Last year, the elder Pok- tractable maladies.“When you tell Pres- in his annual State of the Nation ad- rovsky appeared before the Duma to ident Putin that we should spend more dress. I ran into Tedstrom on the street say that there may be at least a million money on AIDS than on heart disease, near his office that afternoon and he and a half H.I.V.-positive Russians, and which kills millions of our citizens now, was excited. When the speech was de- that in cities like Irkutsk and Samara he will ask why.And the answer—that it livered, at the end of May, Putin never at least one per cent of the adults were will kill a few million people in twenty uttered the word “AIDS,” though he already infected. The speech changed years—is not going to be good enough did find time to warn foreign human- nothing. for him.” rights organizations to stay out of Rus- Pokrovsky finds himself saying today Putin is what the Russians call a sia’s business. exactly what he said in 1990. “I never poryadochny chelovek, a man of order imagined we would have three hundred and discipline. He has nearly total con- t will be at least a decade before the thousand H.I.V. infections,” he told me. trol of the government; the country re- Ifull force of the epidemic is felt in “Fifteen years ago, I was certain we would mains a place where decisions flow from Russia. The virus can take that long to see the scope of the problem and do the top, and until the President makes destroy the immune system. Until then, what was necessary to stop it. And now AIDS an issue the apparatchiks who a person can seem healthy and may even I am in the position of saying to myself, spend their lives trying to anticipate have no idea that he is about to die—and ‘I am certain that we can prevent mil- his desires are unlikely to do so, either. that is the case with hundreds of thou- lions of infections in this country.’ But “This is the first country with a declin- sands of Russians today. By 2010, many sometimes I wonder. Why am I certain? ing population that AIDS has hit in this of them will need daily antiretroviral What has happened to give way,’’ Steven Solnick, the treatment. me confidence? And, really, Ford Foundation’s chief According to Russia’s Federal AIDS the truth is we should all representative in Russia, Center, last year the number of H.I.V. be afraid, because we have told me.“And that changes infections actually fell by some twenty- done very little here in Rus- everything. It makes the five per cent, but that is partly because sia. If the situation does problem more urgent, of the central government has stopped sup- not improve, there will be course, but in the Kremlin plying H.I.V.-test kits to Russian re- at least five to seven mil- it creates a complicated po- gions; many local governments sim- lion cases within fifteen to litical dynamic. AIDS gives ply can’t afford to buy them, so fewer twenty years. Seven million the forces that are hostile people are tested. “We have been try- people who are sick and dying of AIDS. to change a reason to enforce a conser- ing to identify what office in the Min- And maybe many more. We will long vative social order. It offers an excuse to istry of Health is responsible for AIDS,” ago have passed our ability to pay for complain about drug addiction, to stress Marina Semenchenko, the doctor in treatment of any significance.’’The Rus- conservative views on family values; it charge of the World Health Organiza- sian government hasn’t put much pres- encourages people to consider placing tion’s AIDS efforts in Russia, told me. sure on pharmaceutical companies; con- restrictions on abortion. “There is no one.’’ sequently, the country has some of the “When Putin has mentioned AIDS, Evidence that AIDS is spreading into highest prices in the world for the anti- he has done so in the same breath as drug the wider population is overwhelming. retroviral drugs that have become the addiction,” Solnick went on. “He is just As recently as 2000, ninety-six per cent standard treatment for H.I.V.The U.N. not a man who is going to go out there of officially registered new cases were

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EZTNY—10/11/04—PAGE 62—133SC.—LIVE SPOT ART 27825—PLEASE INSPECT AND REPORT ON QUALITY—#2 PAGE convenient transit point for heroin from Afghanistan, the AIDS problem has be- BOY WITH A HEADSET come more urgent than in most other Russian cities. Drugs have flooded the He is wearing baggy shorts and a loud T-shirt streets since the late nineties, and these and singing along to his headset on Broadway. days you can buy a dose of heroin for a Every now and then he glances back at me, hundred rubles, or about three and a half a middle-aged father weaving through traffic behind him. dollars—an attractive offer in a city full of unemployed young people with little He is a fifteen-year-old in the city—no more, no less— prospect of a future. Between 1991 and but I imagine him as a colorful unnamed bird 1998, health officials in the Irkutsk re- warbling his difference from the robins and sparrows gion registered fewer than fifty people and scissoring past the venders on every corner. infected with H.I.V. By the spring of 1999, a state of emergency had been de- I keep thinking of him as a wild fledgling clared. Doctors diagnosed dozens of who tilts precariously on one wing new infections every day. Last year, the and peers back at me from the sudden height region, with two per cent of the Russian before sailing out over the treetops. population, registered more than twenty per cent of the children born to H.I.V.- —Edward Hirsch positive mothers. There is information about AIDS available in Irkutsk, but nobody seems attributed to intravenous drug use. By emotional center of Siberia; during the to know where to find it. You certainly 2002, the number had fallen to seventy- Soviet era, a group of writers from the don’t see public-service announcements six per cent. Last year, it fell again, to region emerged as almost accepted voices on state-run television or hear them on sixty-four per cent. The male-to-female of protest. They never criticized the the radio. I never noticed a billboard or ratio of infection also began to shift in Kremlin directly,but by focussing on the read a newspaper advertisement. (For 2002, and there was a two-hundred-and- land—the natural, mystical beauty of that matter, newspapers and magazines thirty-per-cent increase in the number historic Russia—they were able to im- have largely stopped writing about AIDS, of babies born to H.I.V.-infected moth- plicitly criticize the regime’s disregard too.) Nobody hands out pamphlets or ers.There has been yet another ominous for the people. Irkutsk is not industrial or canvasses night clubs or explains the sign: the rising rate of syphilis infec- academic, like Novosibirsk; it’s a one- risks to schoolchildren. Not surprisingly, tions, which has proved to be an infalli- horse town that just grew. The city has since very few people have actually fallen ble barometer for the incidence of H.I.V. its share of oppressively monumental ill, fear is limited. “Sometimes I think I Greece reported no syphilis infections in Soviet architecture—memorials to fallen don’t know anybody who isn’t using or 2001; the Netherlands reported less than soldiers of the motherland, the stolid hasn’t used heroin,” a young H.I.V.-pos- one case per hundred thousand people; headquarters of the Communist Party itive woman named Sveta told me one Turkey had five cases per hundred thou- (now the administration offices for the afternoon at the local Red Cross drop-in sand; Iceland had just over eleven. Rus- regional government), and scores of the center. Sveta is twenty-two, with long sia, however, had a hundred and forty- cinder-block housing projects that helped reddish-brown hair. The day we met, four cases. The H.I.V. epidemic passes a make residential life in the Soviet Union she was wearing a short leather jacket critical boundary when one per cent of such a numbing experience. But even and green corduroy pants. She had a adults become infected; that figure has Stalin couldn’t fully erase the wildness gold wedding band on her left hand and turned out to be a sort of trip wire. After of Siberia, and one can still find some a large green ring on her right. Sveta has that, the virus becomes much more dif- of the original wooden houses that were a three-year-old son, Simyon, and she ficult to contain. In many parts of Rus- erected when Nicholas I exiled the De- told me that she had tried heroin a few sia, that one-per-cent figure has now cembrists from St. Petersburg, in the times with a friend, out of boredom. She been reached. nineteenth century. Many of the houses said that her husband was not infected are falling apart—they tend to sink and that they were both unemployed. “I n the middle of April, I flew to Ir- deeper into the ground with every spring didn’t know you couldn’t share needles,” Ikutsk, just in time for the last snow- thaw. But they bolster the city’s image she told me. “It just seemed like the ob- storm of the season. Within a couple of as a sort of frontier outpost between the vious thing to do.’’ She said that she was hours, several inches were on the ground; European part of Russia and the wilds grateful that her son is not infected, but then, almost as quickly, the snow disap- to the east. that she took no particular precautions. peared, blown away in gusts. The city, For centuries, Irkutsk has been one “I was lucky,”she said.“Most of the peo- sixty-five kilometres from the shores of of Siberia’s most important trading cen- ple don’t care about their health. They Lake Baikal, was dark, cold, and unin- ters, with merchandise moving constantly just want drugs. Well, there are no jobs viting. Baikal is the spiritual home of along the routes between China and here. Nothing much to do, and there are modern Russian nationalism and the Russia. Now, because it has become a lots of drugs. If you go to school, you

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TNY—10/11/04—PAGE 63—133SC.—#2 PAGE TNY—10/11/04—PAGE 64—133SC.—LIVE OPI ART—RICHARD AVEDON—1975—#2 PAGE—THIS IS AN EXTREMELY CRITICAL CUT THAT SHOULD BE WATCHED THROUGHOUT THE PRESS RUN—PLEASE PULL A KODAK APPROVAL AND CALL TO REVIEW COLOR. have to pay in order to pass your exams. POSTSCRIPT I finished school, but who wants me? To get a job in a shop, you have to bribe somebody or pay them part of your RICHARD AVEDON wages. So that means I can work in a kiosk on the street.’’ Sveta comes into the city from a village about an hour away to see a psychologist whom the Red Cross makes available for counselling.“I have a lot down inside of me, and it’s good to o know Dick Avedon was to know were the solid, mineral form of talk to somebody,’’ she said. Tthe sun. He radiated out, early and what was, in the fashion pictures, pure We were sitting in the tiny office of daily, on a circle of friends and family and liquid. Both were studies in human the drop-in center, in a muddy courtyard colleagues, who drew on his light and performance: how we prepare a face to off Karl Marx Street. The Red Cross warmth for sustenance. When he died, face the world, and how the world was the only organization in Irkutsk that last week, at the age of eighty-one, some shows itself in our faces. As long as seemed to understand the seriousness light seemed to go out in many lives and people remain curious about life in the of the threat posed by H.I.V. Every- around many pleasures. For, though he twentieth century, they will turn to where else, I encountered willful blind- was incandescent in his presence, he was Avedon’s photographs to see how it ness and almost complete denial.“Every surprisingly domestic in his enthusiasms; looked, and what it meant. tenth person in Russia believes that AIDS he believed in family as passionately as he When Tina Brown brought him doesn’t exist,” Marina Akulova, the leader believed in art, and could leave an hour- to The New Yorker, in 1992, to be its of the Irkutsk Red Cross, told me when long conversation about Goya’s horrors first staff photographer, she was I asked about the attitude. “Another to talk with the same avidity about how rupturing a long-standing taboo ten per cent believe it can’t possibly af- to light a room or roast a leg of lamb. against photography, and even those fect them.’’ In the arc of a career that stretched who loved his work might have had I was even told, by Aleksandr Goliu- for sixty full years—from the epoch- their doubts. But his photographs, in sov, of the Ministry of Health, that the making postwar Parisian fashion their epigrammatic compression of a infection rate in Russia wasn’t nearly as photographs in Harper’s Bazaar to whole subject into a single black-and- bad as Western experts have asserted, the exhibition of his portraits at the white image, were New Yorker profiles and he implied that the West was sim- Metropolitan Museum two years ago— in miniature, and within weeks it was ply trying to humiliate Russia by in- he suffered, just a little, from the as if they had always graced these pages. flating the figures and comparing them knowledge that the vigor of his presence His subsequent work for the magazine to Africa’s. He was not the only person might eclipse the rigor of his work. But ran from an inventory of the faces of to say this to me. “Isn’t much of this the two sides of his nature, and his Kennedy’s Camelot thirty years later to coming from your C.I.A.?’’ he asked, psyche, were really one. Though he held the enchanted portraits of singers and with some justification. The American a tragic view of life, he brought to that actors that he made in the past year. intelligence community has for several view a grace and mischief and energy In the last weeks of his life, he was years been openly concerned about the that stripped the existentialist position completing his most ambitious project security threat that a rampant epidemic of its sourness and made despair about for the magazine, a survey of America in Russia would pose; it is hardly a con- the final outcome of life a reason to on the eve of the election, to be called troversial assessment, though, since Rus- live all the more. His best-known “Democracy.” He was getting ready to sia maintains an enormous arsenal of photographs, from the Parisienne take one more portrait when life fled nuclear weapons. “I can only work with leaping over a puddle in high heels to from him. If to know him was to feel the numbers we have,’’ Goliusov said. his dying father’s desperate face, all share in the presence of the sun, to look back “We receive requests for service and a belief in the heroism of self-assertion, on his life is to see that what we really medication based on those numbers. a belief that every leap is a leap of faith. experienced was the track of a comet: The C.I.A. has issued a report saying His definitive portraits of the powerful breaking barriers between spheres, that from three to five million people and the powerless—encompassing, in a shattering fixed orbits, bringing joy and are infected with H.I.V. in Russia. manner almost without equal in the amazement and portents of change to That simply is ridiculous. I can agree history of portraiture, the artistic and those looking on below, and coming to that not every case is reported or counted political hierarchies of the past half rest at last in earth, still fully alight. properly. But the number that for- century of American life—were almost eign observers say need medicine now Roman in their severe authority. But they —Adam Gopnik is fifty thousand. That is just wrong. were not the negation of his dancing What the international organizations and delighted fashion photographs, as do is they apply mathematical mod- critics sometimes thought: the portraits els, and they said if there are seven hundred and fifty thousand infected Richard Avedon, summer, 1975. you should have fifty thousand who

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TNY—10/11/04—PAGE 65—133SC.—#3 PAGE are sick. But that is theory, and reality gerous, and, one of them told me hon- place in the city to buy heroin and to is what I get coming into hospitals estly, the city has been receiving bad pick up a fresh dvoushka, one of the two- and clinics.’’ publicity. Nonetheless, I was introduced millimetre syringes favored by Irkutsk to Misha and Alyosha, both former her- drug addicts. ussia is one of the world’s best- oin addicts in their thirties who travel We drove down a narrow, shabby R educated nations—the literacy rate frequently to Trety Posyolok, the neigh- street. Garbage was strewn everywhere. is above ninety-nine per cent. But, in a borhood where heroin is sold openly. Gypsy touts and homeless women stood poll conducted last year, two-thirds of They were willing to let me tag along on the corners rubbing their hands to- the respondents who knew that AIDS is when they delivered clean needles to a gether to keep from freezing. The mo- caused by H.I.V. also believed that it can friend who distributes them there. ment we parked, a toothless man wear- be contracted through kissing; We flagged a taxi. The ing a Los Angeles Lakers sweatshirt a majority of Russians think driver raised an eyebrow when approached. “You want it?’’ he asked. you can get AIDS from a cough; he heard the destination. But “A hundred rubles. Very clean.” Drug and three-quarters believe that money is money, so he nod- deals are done both on the streets and the virus can be transmitted ded and we piled in. As we in the houses. Each location has its by mosquitoes. None of that, talked, the driver immediately dangers; the main street leads to a hill, of course, is true. While I was jumped into the conversation. and at its end is the regional police acad- in Moscow, two acquaintances “One day,” he said, “I had a emy.We watched as, every few minutes, of mine—both successful pro- guy come in and he wanted to fresh-faced recruits, none more than fessionals with access to people buy drugs. So I said O.K. and eighteen years old, walked awkwardly at the highest levels of the I took him up the hill.’’ The down the hill, guns strapped tightly Kremlin and of Russian life— driver fell silent, then contin- to their hips, as they pretended not to were astonished to learn that it ued, “He went into a house see what was happening all around takes many years for a person to buy his stuff and then he them. Misha and Alyosha took me to a to become sick after being infected with came out, and before I could say a word rickety old house halfway up the street. H.I.V.That the virus goes about its busi- he had a needle in his arm and he was Two large but seemingly docile dogs ness silently, destroying the human im- shooting up in my taxi.” This was a cou- responded to the doorbell. They were mune system without warning, is one of ple of years ago, he recalled, at a time quickly followed by their owner, a thin, its defining characteristics. If there were when the heroin sweeping into the area hawk-faced man with a ponytail and a no time lag between infection and ill- was particularly potent. The passenger cigarette dangling from his lips. The ness, AIDS would not have been so insid- overdosed and started to choke.“He was man’s name was Volodya, and he is the ious, and so difficult to understand. One dying right in the back of my car,’’ he most effective preventive weapon against Russian woman I have known for years, said. “I had to rush him to the hospital AIDS in the neighborhood, because each a prominent liberal, said, “AIDS might and explain what happened. I am lucky week he hands out clean needles to any- be a good thing, in a way, because it is they didn’t throw me in jail.’’ We asked one who asks. killing people who only destroy the coun- if the man had lived. “I don’t know,’’ the Distributing clean needles occupies a try anyway.’’ driver said. It was clear that he didn’t gray area in Russian law. Most people as- She was talking about drug addicts. care. We drove across the Angara River, sume that it encourages drug use, and The Russian government has been par- and soon we passed a line of cabs.“Her- many officials oppose it for that reason. ticularly unwilling to treat substance oin taxis,” he said. “These are the cars (In fact, the participants in a major AIDS abusers as citizens in need of help in- willing to take people to Trety Posyolok.” conference held in St. Petersburg this stead of as criminals. A highly critical He told us that most cabs didn’t want to May took a stand against distributing report by Human Rights Watch noted bother, and that since his near-death in- clean needles.) In some cities, including earlier this year that H.I.V.-infected ad- cident a couple of years earlier he hadn’t St. Petersburg and Irkutsk, AIDS orga- dicts are often barred from the type of been back. nizations have made efforts to explain education and outreach programs de- Trety Posyolok is not much more than to the police why they are beneficial. signed to help them. Even in prison, a collection of wooden houses, muddy, Volodya says that he isn’t hassled much which itself is a notorious incubator for half-paved roads, and seedy kiosks scat- anymore, though police in Irkutsk are H.I.V. and for tuberculosis, inmates tered along the southern edge of Irkutsk. certainly not eager to talk about their rarely have access to treatment. The re- The Posyolok—the word means “set- approach to needle exchange or narcot- port argues persuasively that the gov- tlement”—is part of the city now, but ics. (I tried to meet with narcotics-squad ernment has made the epidemic far it was created in the nineteen-sixties as officers while I was there. They told me worse by routinely mistreating and vic- a separate village, the third in a row that they could speak only with the per- timizing those who are infected. The of identical places all thrown together to mission of Moscow, which I had not attitude toward drug use is so uniformly house workers assigned to build the obtained. I then called the head of the harsh that the people at the Red Cross power station that still dominates the local police. He also refused to see me.) in Irkutsk were reluctant to send me area. Few of the streets have names. Al- Volodya was hardly surprised to hear into neighborhoods where heroin is most everyone who ventures there knows this. “All we have to do is pay some bought and sold. They consider it dan- where he is going and why: it’s the best bribes,’’ he said with a shrug. “Some-

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TNY—10/11/04—PAGE 66—133SC.—LIVE SPOT ART 25804-B times it’s just give them condoms and ant middle-aged man, and he welcomed those who come to us with the appro- other times money. But if people come me with the type of hospitality that was priate diagnoses,” Tsvetkov said. “The to my house to get needles and they have common among mid-level Soviet offi- number right now is sixteen. I know that drugs they can be busted, and so can I.’’ cials: he made tea, took a box of choco- it will change soon and that we’ll need There was a knock on the door. Two lates from his desk, tore off the cello- money from the government. But in the men stood silently on the stoop. Volodya phane, and insisted that I eat. last two years the number of infections pulled out a shoebox full of neatly pack- Tsvetkov told me that the severity has gone down.’’ He shrugged.“It’s meant aged two-millimetre syringes. Then he of the problem in Irkutsk was often ex- that it has been hard to get money from took a few individually wrapped alcohol aggerated. “All the responsible parties, the central government. There is a feel- swabs from his pocket. The men took from the police to health organizations, ing in many places that the problem is them, nodded sullenly, and were gone. work together to fight the virus,” he said. going away. We know very well that is The entire transaction lasted less than “We coöperate.” I asked why the police not true.” He said he was aware that thirty seconds. refused to talk about the relationship be- Irkutsk was gaining a reputation as a Volodya has used drugs for years, but tween drug use and AIDS. He shrugged. center of the AIDS epidemic in Russia. his main interest in life is heavy-metal “That’s a difficult issue,’’ he said, but he He was not pleased. “We do acknowl- music. He has nearly a thousand records, would not elaborate. He acknowledged edge the problem,” he went on. “Still, and he plays them day and night. He that in Irkutsk, as in many other parts of we are experiencing nothing more and showed me the cover of the album that Russia, a fundamental shift is now under nothing less than what the rest of the was currently rattling the windows of way, with the epidemic moving from its country experiences. It’s not easy now, the house,“1000 Percent Metal Ballads.’’ base among drug users to people who are and it’s only going to get harder. In two He talked at great length about the rela- infected through heterosexual contact. or three years, I know, it will take our en- tive merits of Metallica, Megadeth, and Statistics are collected in a haphazard tire health budget just to treat people for Aerosmith before mentioning that he way,but they tell a story that isn’t hard to H.I.V. And when that happens I am not had travelled to Moscow in 1995 to see a understand: in 1999, more than ninety sure, really, what we are going to do.’’ performance by Deep Purple—his fa- per cent of those who tested positive for vorite group by far. “It was worth every H.I.V. in the region were intravenous he man who for decades has paid minute and all the costs,’’ he said with a drug users. Today, that number is sixty- Tthe closest attention to the Russian smile of the deepest possible satisfaction. five per cent. “And I know that we are population crisis is not even Russian; Volodya is available all day to pass able to catch at most only half of the in- his name is Murray Feshbach, and he out clean needles to anyone who knocks. fected people,’’ Tsvetkov said. He added works in Washington, D.C. Feshbach, a “Why?” I asked, waving away a thick that doctors were treating fewer than scholar of Russia, statistics, and lies, cloud of cigarette smoke. “Clearly, it’s two dozen people in the region with an- started telling people in the nineteen- dangerous. Why bother?” tiretroviral drugs. “It just hasn’t become seventies that the Soviet Union was so He looked mystified.“I can deal with that big an issue yet,’’ he said. I asked frail that it was in danger of falling the police,” he said.“I have lots of friends, how, in a city of more than half a mil- apart. Nobody wanted to listen. The they all use drugs, and I would like them lion, with one of the country’s highest Soviets lied about health statistics, and to stay alive.’’ AIDS-case rates, there could be so few during the Cold War few American The next afternoon, I drove to the people on antiretroviral drugs.“We treat leaders were willing to believe that their Irkutsk Infectious Disease Hospital.The complex is far from the center of the city and is difficult to reach. It was nearly de- serted. Every significant city in Russia has an AIDS center. Moscow’s is a crum- bling shack situated near the back of the Second Hospital for Infectious Diseases, the main hospital for H.I.V. in the capi- tal. It was marked by a small plaque. Irkutsk’s center was in better shape, but it is tucked away on the grounds of the hospital complex, behind a large build- ing, and is marked by the smallest imag- inable sign, written in white paint on the side of a red brick building that almost nobody ever sees. The writing looks like graffiti (except that nobody writes graffiti that small): “Tsentr SPID”—SPID being the Russian acronym for AIDS. I had come to see the chief of the region’s AIDS unit, Dr. Boris Tsvetkov. He was a pleas- “I won’t, of course, Hollingsworth, but I could have you killed.”

TNY—10/11/04—PAGE 67—133SC.—LIVE OPI ART A9829—#2 PAGE officially recorded, the number of in- fected children born to women who were not drug users is seventy-five hundred. But seventy-five per cent of them were born in the past two years.’’ The military will be hit particularly hard. Although the Russian government has said that it intends to maintain armed forces of a million men for many more years, it is unlikely to succeed. After 2005, the number of seventeen- and eighteen- year-olds eligible for military duty will decline sharply, the result of the baby bust of the late nineteen-eighties and early nineties. Soldiers are at much higher risk for H.I.V. than other mem- bers of society: young men are prone to risky sexual behavior, often relying upon prostitutes during long tours of duty away from home, and drug use is com- mon. In 2002, only eleven per cent of the men called to serve were considered fit for duty; five thousand draftees tested positive for H.I.V.and were turned away. In fact, in the past five years the number of draftees with H.I.V. has increased twenty-five-fold. Last year, a quarter of “I was in a different place then.” those who entered the armed services during the spring draft had less than nine •• years of education, which means that they could not be trained to use the ad- vanced equipment that is central to the mighty adversary in the great battle for looks like an owl and seems to possess a success of a modern army. ideological and physical supremacy copy of every number or population sta- “The military is a complete disaster could actually be sickly and weak. But tistic that exists. His workspace at the area—prosto koshmar,’’ Feshbach said, Feshbach—first while working for the Wilson Center was strewn with arcane using the Russian words that mean “sim- U.S. Census Bureau, then as a professor monographs, charts, and books like “In- ply a nightmare.” Russian defense plan- at Georgetown University, and now as a fections and Inequalities: The Modern ners have even floated the idea of creat- senior scholar at the Woodrow Wilson Plagues,” “Pathologies of Power,” and ing a foreign legion for Russia. In the International Center—has spent his life “The Wellbeing of Nations.” There coming decade, it may be the only way to plowing through obscure data in other- were stacks of data sitting on his desk maintain the Army. “The situation is wise unread files. He has never wavered and a pile of the articles and studies that awful, horrendous, terrifying—any word from his view that disease and the ef- he was most interested in at the mo- you want to use,” Feshbach said.“Russia fects of environmental poisons are the ment; they ranged from the demograph- badly wants a modern military, but you biggest threats that Russia faces. His ics of Bulgaria to the economic impact have to have a certain skill level to do books—“Ecocide in the U.S.S.R.,’’ of sexually transmitted diseases in Cen- something more than just run and stop about the horrendous environmental tral Asia. and shoot. And when there are fewer damage done by the Soviets, and a re- “What do you think it’s going to take soldiers what will the generals rely on?” cent volume on Russia’s demographic before Russia starts to respond to AIDS Shaking his head, he answered the ques- crisis—are impossibly grim. Eventually, seriously?’’ he asked me, then quickly an- tion. “Nuclear weapons, biological though, American leaders, and then swered his own question. “More deaths. weapons, and chemical weapons,” he many of the Russians who had once Many more deaths. Not enough have said. “That is what scares me the most. mocked him, began to admit that Fesh- died yet.” He began to recite statistics. Russia has a view of itself as a super- bach was right. “The demographic is moving, it’s mov- power, and this is the only way it can I went to see him one day not long ing right now,’’ he said, meaning that the support that view. The country can only ago, just a week before he was scheduled epidemic was switching from one pri- become more unstable as it becomes to fly to St. Petersburg, where he was to marily among drug users to one with a sicker, but its leaders cling to their view receive an award for his work. Feshbach significant base in the wider population. of Russia as it existed when there was a is a heavy man with thick glasses who “You can see it in pregnant women. As Soviet Union. They want to be com-

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TNY—10/11/04—PAGE 68—133SC.—LIVE OPI ART A9871—#2 PAGE pared with us, not with Ghana. AIDS What is happening in Russia right now industrial nations. The country’s leaders will not permit them to do that much is going to define, to a large degree, the often mention AIDS in public at inter- longer. This epidemic will alter the way future of the AIDS epidemic globally.Yes, national gatherings, acting as if Russia families are formed, and change the the country escaped for twenty years, still had an empire to control. At home, labor force completely, not to mention but now it is confronted with possibly a though, the story is different. “Russia the way cities are built and populated.’’ disaster. And the impact, the size of the went ahead and made a decision to Feshbach added, “It’s going to be an ep- population, and the geography mean contribute money to the Global Fund,’’ ochal reshaping of that part of the that it will have a direct influence on Christof Rühl, who was until recently world.’’ what will happen in Europe, in Central the World Bank’s chief economist in As the number of people in the Asia, even in China and India. And that Russia, told me. The Global Fund to working population shrinks, so, natu- will have an impact on us. It’s hard to Fight AIDS was set up by the U.N. to rally, will the gross domestic product. imagine a more critical country at a more provide money for those countries which Russia may lose as much as eight per critical moment.” cannot on their own defeat AIDS, tuber- cent of its annual income, but experience culosis, or malaria. I talked to Rühl one from other countries demonstrates that ow many fact-finding tours of day when I was in Moscow. He was tak- the repercussions from H.I.V. are far Hsouthern Africa, of India, and of ing a break from a conference on West- larger than what one would expect sim- various countries in Eastern Europe will ern investment, held at the Radisson ply by subtracting the money earned Russian officials take before they see the SAS Slavyanskaya Hotel. Men in Val- by those who are sick. People have to implications of the epidemic that is now entino suits were talking on cell phones be fed, clothed, and taken care of, and spreading rapidly within their borders? and smoking huge cigars. Their drivers that hurts productivity as well. If your Why does Brazil, with a comparable and bodyguards, all clad in thick black best friend is dying of H.I.V., you are population and a slightly lower per- leather, stood smoking cigarettes pa- less likely to concentrate at the work- capita income, spend nearly a billion tiently by the coatroom. place and less likely to volunteer for the dollars on AIDS each year when Russia Russia invested just over four million night shift, and, more than that, if your doesn’t spend even a tenth that? It can’t dollars in 2003 in its federal AIDS pro- son or mother is dying you don’t go be poverty; Russia is not rich, but it gram, but it committed twenty million to work at all. AIDS also changes the has eighty-five billion dollars in its fi- to the Global Fund to Fight AIDS.Two way a society thinks. In most countries, nancial reserves. The Kremlin is cer- years ago, the Kremlin’s protracted ne- the principle of saving is easy to under- tainly capable of spending money when gotiations effectively delayed a hundred- stand: if you put money aside today, it wants to: last year, for example, the and-fifty-million-dollar loan offer by the somebody will use that money to pro- lavish three-hundredth-birthday party World Bank on the ground that it did duce shoes or a computer or to build a for the city of St. Petersburg—Vladi- not wish to incur further foreign debt.“If house tomorrow. In Russia, people will mir Putin’s home town—cost $1.3 bil- you watch,” Rühl said, “you will see the die too soon to take advantage of any lion. There are more billionaires in Rus- President and all the ministers and the of that, so they are not likely to consider sia today than in any other country— economic advisers going out and saying investment or saving for the future to be at times, they seem to be buying every- to the world, with great pride, ‘Russia worth the effort. In countries where AIDS thing that is not nailed to the ground, is a donor country. We are one of you. has taken a large toll, people quickly from yachts and British soccer clubs to We are going to help solve this health learn to consume what they have. The Malcolm Forbes’s collection of Fabergé crisis for these poor nations.’ It is cheap savings rate plummets, and the econ- eggs.“Do you think for one minute that and cynical. It has not been about H.I.V. omy suffers badly. if Putin called these people into a room at all. It was to say,‘We are a country that “I think Russia will get desperate,’’ and said we have a crisis and we need helps; we don’t need handouts, like Af- Feshbach said. “People will eventually to come up with some money for AIDS rica.’ But the truth is that the govern- see where they are going, and they will they would say no?’’ a senior interna- ment is so disorganized and so removed get desperate. There are people who say tional health official asked me. “Do you from the needs of its own people that Russia will die. I don’t know. But it will think that anyone in Russia can begin to it could not even help get one appli- be weak and unstable. How can it not? justify spending just a few million dol- cation filed for the first round of this Right now, the state is doing nothing, lars on AIDS each year? There are people Global Fund. and if the state doesn’t address this basic there who spend that maintaining their “The people just don’t care. On a problem what does it address? I have private jets.” very broad scale, it’s a country where heard every excuse for the lack of initia- The Kremlin demands to be taken people care about their family and their tive: fate, that the Russians don’t care if seriously as a world power and as an friends. Their clan. But not their so- they live or die, that they don’t under- active member of the Group of Eight ciety. Yet they have this attitude that stand life, that AIDS is too much of a we are a great power. A donor nation. stigma. I have heard that it’s just about What does that really mean? It means these promiscuous people, that it’s bad you pay a few million dollars to the stuff coming from the West, that it’s world AIDS fund even though you are the wrong crowd.” He concluded,“Who too stupid to attempt to profit from it cares what the reason is? Who cares? when your own citizens are dying.’’

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