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Richard Stone, International News Editor for the journal Science, last month traveled to Pyongyang, in the Democratic People's Republic of Korea (DPRK), to check in on the country's only laboratory capable of detecting strains of drug-resistant tuberculosis.
While the overall incidence of tuberculosis (TB) worldwide has gone down in recent decades, the bacteria that cause TB are steadily developing resistance to treatments. North Korea is a newly recognized hot spot for multidrug resistant (MDR) TB strains. The article about Stone's trip to North Korea appears in the 26 April issue of the journal Science, which is published by the American Association for the Advancement of Science.
The rise of TB in North Korea has been swift. According to a 2012 report by the World Health Organization, between 1994 and 2011, reported cases went from fewer than 50 per 100,000 people to 380 cases per the same. Today, the incidence of TB in North Korea is second only to that in sub-Saharan Africa.
Several complicating factors have allowed TB to take such a strong hold here, first of which was a four-year famine that started in 1994 and left the malnourished survivors highly susceptible to TB infection. A shortage of TB drugs at the time and a tendency of locals not to comply with the therapy recommended by doctors have only made matters worse.
Today, the country's health ministry estimates that up to 15% of patients with TB fail to respond to commonly used first-line TB drugs, which suggests they are carrying drug-resistant strains. Neighbors, like China, are worried; MDR is difficult to treat even at top-tier health programs.
But promise is shown in ongoing efforts, including the establishment in 2010 of the aforementioned lab, the National Tuberculosis Reference Laboratory (NTRL). Built with the help of the Stanford-led Bay Area TB Consortium and DPRK's Ministry of Public Health, it provides a rare example of scientific collaboration between the United States and North Korea. The collaboration was made possible, Stone reported, by Christian Friends of Korea (CFK), a humanitarian organization that has been supplying aid to DPRK for 18 years.
In March, along with several CFK members including CFK executive director Heidi Linton, Richard Stone went to visit the NTRL lab. Also on this trip was Stanford microbiologist Kathleen England, whose priority is to see that the NTRL facility wins international accreditation. She hopes this will happen by 2015. If it does, the lab can join the global fight against TB.
While England said she is happy with the lab's progress so far—the facility has begun molecular testing, and it recently acquired a machine used to detect multidrug resistant TB strains—she acknowledges that much remains to be done to bring it up to speed and make inroads into the MDR problem. She presses on, training the 14 NRTL staff and establishing quality control measures. Soon, she said she plans to conduct a survey on drug resistance.
In addition to visiting the National Tuberculosis Reference Laboratory, Stone visited the pediatric ward of a TB hospital in Pyongyang. Though the pediatric ward wasn't very crowded during Stone's visit, staff explained that they expect to see more patients later in the spring, when people who'd stayed huddled during the winter months are willing to come out. One physician working at the hospital pointed out that children are easier to treat than adults because they are eager to follow doctors' orders.
Farther afield from Pyongyang, Stone visited four rural rest homes, where TB patients go for care. Linton came along to assess the health of these small facilities, evaluating things like how many doctors, patients, and beds each one had, and whether drug stocks were sufficient.
"This was my fifth trip to DPRK, and my first opportunity to experience the bleakness of life in the countryside," Stone said. "The TB epidemic only adds to the hardship of villagers who depend on government food rations for survival."
To supplement diets of people in rural rest homes, CFK donates several tons of canned meat each year.
In one rest home Stone visited, he found mixed news. The number of MDR cases had stabilized, but patient conditions had worsened. Scientists are not sure what strains are circulating in North Korea, and continued work is needed to identify them so that effective treatments can be developed.
Stone noted that his trip to North Korea came at a delicate time, as South Korea and the United States were conducting annual military exercises that included stealth bomber flights over South Korea.
"Our visit took place during heightened tensions with the West. It didn't escape our attention that the seven of us were the largest group of Americans there at the time," Stone said.
He said he didn't feel overly anxious, however. "Our hosts with the Ministry of Public Health seemed genuinely concerned about our welfare. I came away with the feeling that the scientists we encountered have good hearts and a real desire to help their countrymen."
The efforts of these scientists will be critical in fighting the TB epidemic in North Korea, particularly as multidrug resistant strains proliferate. Indeed, some hope that the presence of the National Tuberculosis Research Lab will be a building block, paving the way for opportunities for scientific collaboration between North Korea and other countries participating in the global TB fight.
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