Vladimir Kara-Murza took ill on the train back from Tver, where he had just exhibited a film commemorating the life of slain Russian dissident and former deputy prime minister Boris Nemtsov. “He joked that maybe Siberia hadn’t agreed with him,” according to a mutual friend. Evidently remote from his mind was that he was about to befall the same catastrophic shutdown of his body that nearly cost him his life two years ago.

Early yesterday morning, Kara-Murza was placed in an intensive-care unit in a Moscow hospital, then put on life-support and into a medically-induced coma. His organs have failed him. As of this writing, no one knows why. Eerily what’s happening is exactly what happened to him before. “The clinical picture, according to his doctors, is the same as last time,” Kara-Murza’s wife Evgenia told RFE/RL.

The last time was in late May 2015. Kara-Murza had just returned from a fairly uneventful lunch in Moscow with a fellow opposition activist from RPR-Parnas, the party to which he and Nemtsov belonged, when he began sweating profusely, growing dizzy and then vomiting before passing out completely. For about a week, and after a time-wasting misdiagnosis of a cardiac defect, his condition deteriorated gravely. His lungs, liver, kidney and heart stopped working and he developed swelling in the brain. Doctors assessed his chance of survival at 5 percent. He was only 33. Nemtsov had been shot in the back just steps from the Kremlin three months earlier in a crime whose true mastermind will never been identified.

Kara-Murza’s caregivers in Moscow attributed his sickness to poisoning, but indicating that it was self-inflicted. The patient, they said, had overdosed on citalopram, a common SSRI anti-depressant he had indeed been taking for years, a claim eagerly lapped up by LifeNews, a media organ with ties to Russian intelligence, to dispel the immediate and natural suspicion of foul play. Perhaps he’d mixed the drug with other contraindicated anti-allergy medication or alcohol, even though he hadn’t been drinking the day he first experienced symptoms? For a time, there was a special emphasis placed on his use of Flonase, the over-the-counter nasal spray which, taken with SSRI drugs, rarely, if ever, kills you.

As such, credible medical experts cast doubt on this theory. Evgenia also noted that her husband’s Russian doctors were quite opposed to performing a more comprehensive toxicology screen and taking new blood, hair, urine and nail samples to have them tested by external specialists. Kara-Murza has dual Russian-British citizenship, and yet the British embassy in Moscow was reliably the picture of stiff-upper-lipped uselessness about the possible murder attempt of one of their own on foreign soil. Unbelievably, he survived.

Kara-Murza’s father, also called Vladimir, was rather straightforward in conversation with the BBC: “He was perfectly healthy before, he’d had no chronic illnesses. It’s clear he’s been poisoned. But by what or who, we don’t know.”

Though we could all guess. Putin’s enemies have had a bad habit over the years of ingesting things they shouldn’t, from dioxin to polonium to killer flowers.

The younger Volodya, as we call him, is an international activist and a fixture in Washington, D.C. where he was formerly the bureau chief of RTVi, a Russian-language television station, and a writer for World Affairs Journal. He is also a long-time friend and colleague of mine.

We worked together at the Institute of Modern Russia, a New York-based think tank, for several years before he left to serve as a chief representative for Open Russia, an nongovernmental organization reactivated by the man who had founded it before he, too, took a trip to Siberia. Mikhail Khodorkovsky, the former oil tycoon whom Putin jailed in 2003 and then unexpectedly released in 2013 after Khodorkovsky served nearly ten years in a labor camp, made Volodya his point-man in the country the oligarch-exile can never return to so long as Putin remains in power. (Full disclosure: Khodorkovsky’s son Pavel was president of the Institute and the family’s trust financed the activities of the think tank.)

If Volodya and I ever quibbled it was about language, and he was always right. Why do journalists always say “Russia,” he’d ask, when they mean “Putin” or “the regime”? He abhors the idea, endemic in the Washington foreign policy establishment, that there was a cultural or historical determinism which fated his homeland to remaining a delicately-managed “Nigeria with snow” or “Upper Volta with nukes.” To him, this was a cheap Orientalism borne of fatalism and stupidity. Why can’t Russia have civil society, democracy and the rule of law? It did once, after the fall of the Soviet Union, however imperfectly and briefly.

Still, so long as justice cannot be had at home, Volodya felt it morally feasible to enlist the United States on his side to hold the unjust accountable when they traveled abroad. He spent much of his time stateside lobbying Congress to pass the Magnitsky Act, a law intended to sanction and blacklist the crooks, thieves and gangsters who now run his country by looting it, only to spend their ill-gotten fortunes in London, Dubai and New York.

Well before Ukraine, Syria, the prospect of a Hillary Clinton presidency, this piece of human rights legislation constituted, in Putin’s imagination, the most exigent threat against him from the West. It was a palpable hit against the murderous kleptocracy he had constructed and whose longevity depended on the West’s see-no-evil connivance.

Being a confidant of one prominent opponent of the Kremlin is risky. Being a confidant of two is pushing it. Being a confidant of three is uninsurable.

In February 2016 Ramzan Kadyrov, the Chechen warlord-president widely suspected of having a hand in the murder of Nemtsov, posted to Instagram a surveillance image of Volodya and former Russian prime minister Mikhail Kasyanov, another RPR-Parnas member, as they were exiting a popular restaurant in Strasbourg, the headquarters of the Council of Europe, to which Russia is a party. They were photographed by Russian intelligence and Kadyrov then superimposed an optical scope, the kind used in long-lens professional cameras, or in high-powered rifles, on the image. He also attached a message: “Kasyanov has come to Strasbourg to get money for the Russian opposition. WHOEVER DOESN’T GET IT, WILL!”

Many in the opposition interpreted it as a death threat and would have regardless of the actuarial timeline. (Nemtsov’s murder was the previous year.) Creepily, however, Kadyrov had used more or less the same phrase, “Whoever didn’t get it, will,” on May 25, 2015—a day before Volodya succumbed to poisoning.

When I saw him, months after his first ordeal, at a restaurant in Washington, he he looked as if he’d lost about 100 pounds. He could only walk with a cane, the result of lingering nerve damage to the left side of his body. In full health, Volodya bears a minor resemblance to Lenin (strong, bald pate; neat goatee, slightly Asiatic mien) and I can remember drawing a perhaps indelicate comparison between two workaholic revolutionaries who eluded their assassins.

Volodya was absolutely certain that he’d been poisoned on orders of the siloviki, the strongmen of the regime. He speculated as to how and where it might have occurred. Here I feel duty-bound to point out that if my friend has got a self-jeopardizing impulse in him at all it is that he is committed to remaining in Russia to carry out his important work. He was going to return to Moscow after he fully recovered. Evgenia and their three children would remain in Washington.

“Are you sure you want to go back?” I asked him that night. “If they missed the first time, won’t they try again a second?”

“What good can I do here?” he answered. “The whole point is to educate Russians about their country and what it can be before an entire generation grows up with no concept of freedom. How can I do that from here?”

I had no response then, but I now I badly wish he had tried to find out.