There's a crisis brewing in North Korea that has nothing to do with nuclear weapons or six-party talks. Tuberculosis has long been recognized as one of the biggest public health problems in North Korea, but there is a disturbing new development: much of the TB in North Korea is resistant to regular antibiotics.
Throughout the course of history, TB has killed more people than all other pandemics combined. The development of modern antibiotic therapy turned this feared plague into a treatable infectious disease. A six-month course of standard first-line TB drugs cures almost all patients with regular TB. But like any other infectious disease, TB can become resistant to antibiotics if not treated correctly. The most serious strains of drug-resistant TB, called "multidrug-resistant," or MDR-TB, don’t respond to treatment with first-line TB drugs. Treatment of MDR-TB relies on older and weaker drugs that are hundreds of times more expensive than regular TB drugs. Even in the U.S., a diagnosis of MDR-TB is very serious. A single patient may require medications costing thousands of dollars, months of hospitalization, and even surgery to cut out diseased lung.
For North Korean patients, MDR-TB is basically a death sentence.
Until now, there has never been any clear scientific evidence that drug-resistant TB is a serious problem in North Korea, mainly because North Korea does not yet have a laboratory with the capacity to do this sort of research. Nevertheless, evidence about drug-resistant TB is not difficult to find. I regularly travel to North Korea as part of my work with the Eugene Bell Foundation, a private non-profit organization that supports patients in the TB sanatoria that dot the North Korean countryside. The doctors who work in these sanatoria have been quite open about the fact that they have patients who are not being cured with regular TB drugs. They’ve suspected that these patients had drug-resistant TB, but they couldn't know for sure without access to laboratory testing.
My research, published today in PLOS Medicine, analyzed sputum samples from more than 200 of these patients and found that the North Korean doctors were indeed correct—87 percent were proven to have MDR-TB.
Why is MDR-TB spreading in North Korea? Ironically, in the area of TB control, the North Korean Ministry of Public Health (MOPH) has followed the advice of international experts to the letter. In 1998, the MOPH asked for help from the World Health Organization to rebuild its TB control program. In 2010, the Global Fund to Fight AIDS, Tuberculosis and Malaria pledged $41 million over five years to strengthen these efforts. Two respected UN agencies, UNICEF and WHO, are responsible for the implementation of the Global Fund project along with the MOPH. Yet this project is so poorly designed that it’s become part of the problem it was intended to solve.
In the Global Fund project, all North Korean TB patients are treated blindly with first-line drugs without first being tested to see if they’re infected with resistant strains. The strategy essentially bets that there are no drug-resistant TB patients in North Korea, or at least that the numbers are so few that the public health impact is insignificant.
This is a dangerous bet. Drug-resistant tuberculosis is a man-made disease, created when TB is treated incorrectly. Treating drug-resistant TB with ineffective regimens provokes the TB to become even more resistant. From a public health point of view, bad treatment is worse than no treatment at all, because it can quickly make the problem of drug-resistant TB worse.
When I first started working as a global health doctor 13 years ago, I met Peruvian MDR-TB patients who described their frustration at being treated over and over with the same first-line TB drugs. But that was when WHO was worried that MDR-TB was too complicated to treat in poor countries. Since then, the Peru national TB program has become a leader in MDR-TB treatment, and WHO now pushes countries to diagnose and treat it more aggressively. Mario Raviglione, Director of WHO’s Global TB Programme, recently described treating drug-resistant TB with ineffective drugs as "complete nonsense," adding, "It is silly to use drugs that there is proven high resistance to, thinking they will work."
It is shocking to see North Korean patients just like the ones I saw in Peru 13 years ago, taking the same first-line TB drugs for the second, third or fourth time. Each time they take these ineffective regimens they desperately hope that the result will be different.
It does not have to be this way.
Treatment of MDR-TB is expensive, but it is more expensive not to treat. It is an airborne, contagious disease, and treatment is the only way to prevent transmission. But the high cost of MDR-TB drugs impedes access to effective treatment in countries like North Korea. The Global Fund was created precisely so that poor countries would have access to treatment for complicated diseases, and it has a long track record of funding MDR-TB treatment programs in other countries. But so far it has provided treatment for only 50 MDR-TB patients in North Korea, not anywhere close to what is required to impact public health.
If the implementers of this project continue to be in denial about the MDR-TB crisis in North Korea, the disease will continue to spread from patients to their families and into communities. Without effective treatment, MDR-TB will eventually threaten public health in the entire Korean peninsula.
In this difficult political climate, the Global Fund, UNICEF and WHO should be applauded for their intention to improve TB control in North Korea. But with TB, good intentions are not enough, and can be dangerous. Only the correct public health strategy can defeat it.
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