USA and North Korea work together on tuberculosis

Abstract

Despite continuing tensions between the USA and North Korea, academics from California are proving that health might be one area where cooperation is possible. Alastair Gee reports.After the death of North Korean President Kim Il Sung in 1994, the country was hit by devastating floods that ruined harvests and caused widespread food shortages. “North Koreans will say that when the Great Leader died, the heavens opened and cried for a year”, says Sharon Perry, an epidemiologist from Stanford University, Stanford, CA, USA, now working in North Korea.The deluges receded, but experts say that they might have contributed to a surge in tuberculosis. Today, the country has a tuberculosis rate of about 355 per 100 000, one of the highest in the world outside sub-Saharan Africa. Perry heads an unusual international undertaking, conceptualised in part as medical diplomacy, to create a national tuberculosis reference laboratory in Pyongyang that will be able to test for drug-resistant forms of the disease.The project was initiated in 2007, when Stanford political scientist John Lewis sought ways to foster better relations with North Korea. After learning of the extent of the tuberculosis epidemic, he met with Gary Schoolnik, an infectious diseases specialist at Stanford's medical school, and Perry to discuss the issue. “He said something at a lunch that changed my career for the next 2 years: ‘The North Korean people are afraid they could die and no one would care’”, Perry recounts.Although the incidence of drug-resistant tuberculosis in North Korea is not known, WHO estimates that about 3% of 80 000 new tuberculosis cases and up to 15% of 15 000 previously treated cases reported every year are multidrug-resistant, based on data from the surrounding region.To grapple with the problem, Perry formed the Bay Area TB Consortium, which includes specialists from San Francisco Bay Area medical schools and public health programmes, Christian Friends of Korea (CFK), a non-governmental organisation based in Washington, DC, named Nuclear Threat Initiative (NTI), WHO, and other organisations. In January, 2008, five North Koreans visited California to discuss collaboration.North Korea has since provided a space for the laboratory at the No 3 TB Hospital in the west of Pyongyang. Stanford, NTI, and CFK have together spent almost half a million US dollars on equipment and logistical expenses.Of course, working in North Korea has presented a distinctive range of challenges, such as navigating stringent US laws intended to prevent the export of sensitive technology, and securing a steady supply of electricity for incubators and refrigerators. Currently, power is intermittent and supplemented by a diesel generator, which is unsuitable for long-term use.And there are other, more prosaic idiosyncrasies. Although the North Korean Government has been accommodating to the researchers, like all visitors they are accompanied by minders and must follow pre-approved itineraries. As Perry describes it, she and her colleagues are not only working to combat a deadly disease, they are also engaged in medical diplomacy. “Professionals have a way of staying under the political radar and trading important information, and engaging in common problem-solving”, she says.The US Government, for its part, thinks such engagements are worthwhile, the US special representative for North Korea policy, Stephen Bosworth, tells The Lancet. “They're not a substitute for substantive negotiations on issues such as the denuclearisation of North Korea, we do not try to justify them in that framework, but we do see a value in their going forward with humanitarian assistance.”Although the project focuses on the diagnosis of tuberculosis, an eventual goal is improving treatment. And in North Korea, the provision of tuberculosis treatment is a fraught issue. A 5-year, $71·75 million grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria is currently being negotiated, however, the process is arduous and must be completed by the summer to avoid disastrous treatment interruptions.For now, if all goes to plan and a steady electricity supply is guaranteed—CFK hopes to raise funds to pay for a cable—the tuberculosis laboratory could be fully functional in 2 years. “I would love to see them do it by 2012”, says Perry. “It's a great year for them. It's the 100th anniversary of the Great Leader's birth.” Despite continuing tensions between the USA and North Korea, academics from California are proving that health might be one area where cooperation is possible. Alastair Gee reports. After the death of North Korean President Kim Il Sung in 1994, the country was hit by devastating floods that ruined harvests and caused widespread food shortages. “North Koreans will say that when the Great Leader died, the heavens opened and cried for a year”, says Sharon Perry, an epidemiologist from Stanford University, Stanford, CA, USA, now working in North Korea. The deluges receded, but experts say that they might have contributed to a surge in tuberculosis. Today, the country has a tuberculosis rate of about 355 per 100 000, one of the highest in the world outside sub-Saharan Africa. Perry heads an unusual international undertaking, conceptualised in part as medical diplomacy, to create a national tuberculosis reference laboratory in Pyongyang that will be able to test for drug-resistant forms of the disease. The project was initiated in 2007, when Stanford political scientist John Lewis sought ways to foster better relations with North Korea. After learning of the extent of the tuberculosis epidemic, he met with Gary Schoolnik, an infectious diseases specialist at Stanford's medical school, and Perry to discuss the issue. “He said something at a lunch that changed my career for the next 2 years: ‘The North Korean people are afraid they could die and no one would care’”, Perry recounts. Although the incidence of drug-resistant tuberculosis in North Korea is not known, WHO estimates that about 3% of 80 000 new tuberculosis cases and up to 15% of 15 000 previously treated cases reported every year are multidrug-resistant, based on data from the surrounding region. To grapple with the problem, Perry formed the Bay Area TB Consortium, which includes specialists from San Francisco Bay Area medical schools and public health programmes, Christian Friends of Korea (CFK), a non-governmental organisation based in Washington, DC, named Nuclear Threat Initiative (NTI), WHO, and other organisations. In January, 2008, five North Koreans visited California to discuss collaboration. North Korea has since provided a space for the laboratory at the No 3 TB Hospital in the west of Pyongyang. Stanford, NTI, and CFK have together spent almost half a million US dollars on equipment and logistical expenses. Of course, working in North Korea has presented a distinctive range of challenges, such as navigating stringent US laws intended to prevent the export of sensitive technology, and securing a steady supply of electricity for incubators and refrigerators. Currently, power is intermittent and supplemented by a diesel generator, which is unsuitable for long-term use. And there are other, more prosaic idiosyncrasies. Although the North Korean Government has been accommodating to the researchers, like all visitors they are accompanied by minders and must follow pre-approved itineraries. As Perry describes it, she and her colleagues are not only working to combat a deadly disease, they are also engaged in medical diplomacy. “Professionals have a way of staying under the political radar and trading important information, and engaging in common problem-solving”, she says. The US Government, for its part, thinks such engagements are worthwhile, the US special representative for North Korea policy, Stephen Bosworth, tells The Lancet. “They're not a substitute for substantive negotiations on issues such as the denuclearisation of North Korea, we do not try to justify them in that framework, but we do see a value in their going forward with humanitarian assistance.” Although the project focuses on the diagnosis of tuberculosis, an eventual goal is improving treatment. And in North Korea, the provision of tuberculosis treatment is a fraught issue. A 5-year, $71·75 million grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria is currently being negotiated, however, the process is arduous and must be completed by the summer to avoid disastrous treatment interruptions. For now, if all goes to plan and a steady electricity supply is guaranteed—CFK hopes to raise funds to pay for a cable—the tuberculosis laboratory could be fully functional in 2 years. “I would love to see them do it by 2012”, says Perry. “It's a great year for them. It's the 100th anniversary of the Great Leader's birth.”