Even a casual reader of Russian and Soviet literature is likely to be struck by its frequent and detailed invocations of country doctors, epidemics, surgery, sanitariums, infection, bloodletting, consumption, asylums, midwives, and madness. The works of Pasternak, Gogol, Dostoyevsky, Pushkin, Turgenev, Solzhenitsyn, and Tolstoy reflect an interest in medical subjects that occasionally borders on the obsessive. Several of Russia’s greatest literary figures—notably Chekhov and Bulgakov—were themselves physicians. Perhaps it is fitting that a society at once so culturally advanced and so linked to a history of rural poverty should be preoccupied with medicine, which represents a kind of...

It is nearly impossible to travel to Badakhshan without pausing to wonder how anyone came to live there in the first place. Whether taking the long-abandoned Silk Road route through the Murghab Desert from Osh in the Kyrgyz Republic—a rugged thoroughfare once patrolled by leopards, vultures, and the magnificent Turanian tiger—or the equally forbidding mountain passes stretching east from the Tajik capital of Dushanbe, one is forced to conclude that such a journey into the void would only be made under duress. And indeed, the history of human settlement in the region is a dismal catalogue of conquest,...

My field assistant Ahmed and I sat with Moom, Rais’s mother, in his traditional Pamiri house.¹ Soot covered the walls and ceiling, leaving a smoky scent in the air, though no fire was burning. Rais and Rahmatekhudo, his best friend from childhood, served us tea while Rais’s children looked on from behind one of the five posts holding up the roof. As we sat on cushions laid on the floor and sipped from our cups, Moom, Rais, and Rahmatekhudo reminisced about the many ways Kuhdeh had changed during their lifetimes—their recollections clouded, no doubt, by the turbulent times they...

As we walked out of a meeting with the team from the Canadian International Development Agency in the summer of 1996, Robert Middleton, the architect of AKF’s humanitarian assistance program in Badakhshan and a senior member of AKF’s Geneva office, patted me on the back. “That went well,” he said.

I was not sure what to think. The meeting, held at the Pamir Relief and Development Programme (PRDP) guesthouse—set along the shore of the Ghund River, its green waters providing a low rushing sound in the background as it flowed into the much bigger Panj River—was the culmination...

Bretton Woods, New Hampshire, is far from Bamako and even farther from Badakhshan. Yet it was there, ensconced amid the beautiful views and craggy ridges of the White Mountains of the northeastern United States, that the seeds were planted for what emerged in the revolving drug fund proposal more than fifty years later.

The United Nations Monetary and Financial Conference, held at Bretton Wood’s regal Mount Washington Hotel—a Spanish Renaissance-style building whose interior was said to have taken 250 master craftsmen two years to complete—was no small event, drawing together 730 delegates from 44 nations for the first...

In his 1904 account of the second Danish expedition to the Pamir Mountains,Through the Unknown Pamirs, explorer Ole Olufsen described Badakhshan’s interaction with the outside world as being “slight,” “partly by reason of the secluded situation of the provinces, shut off as they are from civilization by the most mighty mountains of the world, and partly on account of the poverty of the people.”¹ As mighty as they were, the mountains of Badakhshan were not high enough to prevent neoliberal ideas from penetrating into one of the remotest parts of the Soviet empire in the aftermath of its collapse....

British prime minister Margaret Thatcher famously noted that “freedom is not synonymous with an easy life…. There are many difficult things about freedom: It does not give you safety, it creates moral dilemmas for you; it requires self-discipline; it imposes great responsibilities.”¹ This could not have been truer than for the inhabitants of Badakhshan, the older generation of whom likened the post-Soviet period to the famine and hardship following the Second World War.

And in the midst of that struggle, it was clear by the summer of 1996 that the revolving drug fund proposal was moving forward regardless of whether...

It took almost a year after deciding in 1996 to proceed with the revolving drug fund before it was implemented. By the time the program began in Khorog in 1997, I had left Badakhshan. Under a new name—Rationalizing Pharmaceutical Policy and Management (RPPM)—the revolving drug fund program expanded one district at a time over the next four years, until by December 2000 all of Badakhshan’s seven districts were included. In its final project evaluation, AKF reported that by January 2004, only 50 percent of the cost of the medicines purchased for the program were being recovered from patients;...