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North Korea: Witness to Transformation

TB Update

by | May 16th, 2013 | 07:00 am

Science—if you have access—has recently published an interesting piece by Richard Stone on developments in TB and TB treatment in North Korea. The good news is to be found in the efforts of NGOs such as Christian Friends of Korea and Eugene Bell who have long worked this issue. Christian Friends of Korea has undertaken a project with the Stanford Medical School, the DPRK Ministry of Health, the Bay Area TB Consortium and some other supporters to set up a National Tuberculosis Reference Lab (NTRL) in Pyongyang. As with all such projects, it succeeded despite difficult odds and because of the persistence and dedication not only of the foreign team but of fearless health workers in North Korea itself.

Which brings us to the bad news. Since the end of the famine, there has been a sharp inflection in TB case notifications (see graph below); moreover, the increases do not appear to be slowing down. There is some debate about whether more aggressive detection is behind the higher numbers; the figures from the high-famine period that suggest lower incidence than South Korea are questionable. But Gary Schoolnik—leader of the Stanford team–thinks that the increase is real. North Korea now has one of the highest incidences of TB outside sub-Saharan Africa.

In the African cases, a major determinant of high infection rate is HIV/AIDS, which suppresses immune response. North Korea does not have an HIV/AIDS problem—at least yet—but Schoolnik believes that famine and chronic malnutrition have played a similar role in weakening immunity and increasing the chances that latent infections will become active. A weak public health system is also consequential: on average, a person with untreated pulmonary TB infects between 10 and 20 people.

But the situation is worse. Treating TB is hard because the treatment regime lasts for a long time. The standard way of ensuring patients take their meds is a protocol called “directly observed therapy, short-course” or DOTS. But you have to have the drugs in the first place, and North Korea has been unable—or unwilling—to prioritize this sort of public health need. NGOs and the market have stepped in; in one of his last visits, Schoolnik was able to purchase TB drugs in his hotel.

The result of these multiple public health failures—from nutrition through detection to treatment—is the explosion of multiple drug-resistant (MDR) strains. These strains pose challenges even to the most advanced health care systems: the drug regimen is even more rigorous and ridiculously expensive: treating a drug-resistant strain can cost up to 200 times the standard four-drug DOTS cocktail. Schoolnik estimates that of roughly 100,000 cases of active TB in North Korea, 8-15% are likely due to MDR strains. This means 8,000 to 15,000 cases that are unrecognized—one of the purposes of building the reference lab—and are thus being treated with regimens that are unlikely to work.

A final issue raised by the Science treatment, and conversations with Schoolnik, is the question of cross-border spread. China is concerned, and it should be; any change in conditions in North Korea that send more people over the border will also send more people over the border with TB. The negative externalities emanating from North Korea are by no means limited to the political-military sphere; infectious diseases don’t know borders either.