Tuberculosis in the Democratic People's Republic

"...TB has skyrocketed in the Democratic People's

Republic of Korea (DPRK) in the past 20 years,

according to the World Health Organization

(WHO).  Famines in the mid-1990s ignited the

epidemic; chronic malnutrition ever since has 

added fuel to the fire." (R. Stone, Science)

    The News Focus article by Richard Stone in the April 26 issue of the journal Science, titled "Public Enemy Number One", provides an enlightening description of the ongoing tuberculosis (TB) epidemic in the Democratic People's Republic of Korea (commonly "North Korea").  Mycobacterium tuberculosis (MTB), the bacterium that causes tuberculosis (TB) infections, stands as the #2 infectious disease killer world wide, second only to HIV.  The MTB bacillus (meaning "rod-shaped", see photo below) generally causes respiratory infections and is believed to reside in a latent form (non-disease causing) in 1/3 of the human population.  Though a terrifying statistic, well nourished individuals with healthy immune systems often will not exhibit signs of the TB pathology while carrying latent MTB.  Further, in countries like the US, with a readily available supply of antibiotics, the rigorous treatment regimen for TB can be accessed and administered when needed.  The ominous rise of multiple drug resistant (MDR) infections - caused by strains of MTB that are no longer killed by the standard set of antibiotics - is challenge enough for a society with proper infrastructure, healthcare, and access to pharmaceuticals like the US (yes, I'm sure we could argue the finer points here, but we shall save this for another day...).  Enter North Korea.  Constantly plagued by famine, shoddy infrastructure, a barely existent healthcare and pharmaceutical sector, and almost unparalleled political and socioeconomic isolation, and it's no wonder that TB is proving to be a scourge comparable to the hardest hit parts of Africa, where TB incidence is correlated with the depressingly high rate of HIV infection (depressed immune systems = high rate of active TB infection), a factor that is conspicuously absent in the case of North Korea.

A micrograph of Mycobacterium tuberculosis cells, the bacterium that causes TB infections.
[Image: Janice Carr and Dr. Ray Butler, Centers for Disease Control and Prevention.]

    This is not the first time Richard Stone has reported on the TB epidemic in North Korea, but it is his most in depth report about the subject that has appeared in Science thus far.  In the 12 March 2012 edition of the journal, Mr. Stone highlighted the gains that had been made in establishing the National Tuberculosis Reference Lab in Pyongyang, the result of a cooperative effort between DPRK scientists and collaborators from the US.  The main US players include a group of Stanford University microbiologists and physicians and the Stanford affiliated Bay Area TB Consortium, the Christian Friends of Korea, or CFK, which is a humanitarian NGO, and the Nuclear Threat Initiative (NTI), a Washington, DC based 501(c)(3) which provided $230,000.00 in start-up funding for the Pyongyang laboratory.  All of the players acknowledge that the linchpin of the entire operation is CFK, led by its dedicated executive director Heidi Linton, who had well established "street cred" in the country after having worked on various other outreach projects in North Korean hospitals prior to the initiation of the TB project highlighted here.  [Interestingly, CFK sprung up from Billy Graham's visits to North Korea in 1992 & 1994, which opened the door for Christian groups in the isolated country.]  The Stanford scientists, including Sharon Perry, an epidemiologist, Garry Schoolnik, a physician at the Stanford School of Medicine, and Kathleen England, a microbiologist, have all spent time on the ground as well.  In an editorial that appeared in Science (21 January 2011), Perry, Linton, and Schoolnik make a prescient point when confronted with the question, "Why should we help these people?":

Since the end of the Cold War in Europe, drug-resistant strains emanating from this epicenter have been tracked into Western Europe, the Middle East, and South Africa. The modern MDR-TB epidemic reminds us that the loss of TB control leaves costly legacies, for which the world community is ultimately responsible.

So, if a strictly humanitarian argument is a hard sell to foreign policy hawks, then the epidemiological argument of containment and control may provide just the right incentive.  Regardless, this unique case shines a bright light on the importance of combating multidrug-resistance through sound epidemiological, medical, and scientific research and interdisciplinary cooperation.

    The current report highlights the milestones and challenges of the National Tuberculosis Reference Lab (NTRL) and reveals the living and working conditions in several North Korean TB "rest homes", centers where TB patients are housed (read: isolated) and cared for.  The most important and obvious point is that the NTRL exists and is up and running.  Kathleen England, the Stanford microbiologist, is now working with lab staff to implement drug-susceptibility tests for specimens taken from TB patients.  These tests will determine the level of antibiotic resistance MTB cultures exhibit from a given patient and will allow medical professionals to make smart decisions regarding treatment regimens and patient care.  The successful establishment of a drug-susceptibility testing protocol will be seen as a major milestone.  There seem to be at least three major challenges that scientists and health care professionals will have to continue to grapple with.  (1)  Consistent availability of antibiotics.  According to the report, "The health ministry has no funds to import TB medications..." and that those produced in North Korea are of "uncertain" quality.  The drug supply is essentially funded by charitable and non-profit organizations.  (2)  The administration of antibiotics - prescribing, dosage, timing of doses, and adherence to drug regimens - is "uncontrolled".  A course of TB drugs must be administered consistently, minimally for many months, and in worst case scenarios - for the nastiest, most drug resistant strains of MTB - up to 2 years.  If the dosage, scheduling, and quality of the drugs are less than perfect, the likelihood of breeding more/worse antibiotic resistant strains increases.  And lastly, (3) a consistent electricity supply.  The labs and clinics obviously need power to operate properly and efficiently.  But, due to frequent power outages, one TB rest home, "isn't even fitted with light bulbs."

    It comes as no surprise that for all the progress that is being made, there still seems to be a long way to go.  Nevertheless, the accomplishments achieved thus far represent impressive scientific, economic, and political feats.  The hope of the scientists and journalists involved in this story is that the TB clinics will be emblematic of international cooperation between countries that are officially still at war with each other.  This is absolutely true for the scientific community and especially for the scientists involved.  However, the sad truth is that as long as the regime in North Korea maintains its totalitarian, combative, and uber-secretive stance on the world stage, things are likely to continue on the slow, arduous path they are currently on.  Here in the US, we would like to think that our foreign policy and diplomacy will end such crises.  But, given current regional and geopolitical circumstances, what happens with the future of North Korea is likely to depend on a different, rising power; China.

- @EJDimise

[I will eventually return to the topic of TB in a future post, with a greater focus on the MTB microbe.]

[Information on this and other NGO activities in DPRK can be found here.]