A fuse is about to be lit on an infectious disease powderkeg in northeast Asia. On 30 June, The Global Fund to Fight AIDS, Tuberculosis and Malaria will pull the plug on its grants to North Korea, which has one of the highest rates of tuberculosis (TB) in the world. The pullout leaves the isolated nation with about 1 year to line up a new source of medicines and diagnostics to combat a deepening TB crisis.
The Global Fund’s decision to sever ties to North Korea perplexes some humanitarian workers and medical researchers who operate there. “We have not gotten any clarity on why they are doing this,” says Kwonjune Seung, a physician at Brigham and Women’s Hospital in Boston and medical director of the Eugene Bell Foundation, a nonprofit in Andrews, South Carolina, that has supported TB clinics in North Korea since 2007. “I would hope it was something extremely egregious,” for the Global Fund “to take such a drastic step.” Some, however, see the move as a negotiating ploy and predict that the organization will be back in North Korea before TB supplies run out.
Since 2010, the Global Fund, a public-private partnership based in Geneva, Switzerland, has spent more than $100 million on TB and malaria control in North Korea through grants managed by two international organizations with offices in Pyongyang—the World Health Organization (WHO) and UNICEF—as well as North Korea’s Ministry of Public Health (MPH). “It has been the biggest outside investment ever in public health in North Korea,” says Kee Park, a neurosurgeon at Harvard Medical School in Boston who leads biannual exchanges with North Korean health care specialists.
By all accounts, malaria control efforts in North Korea have been a clear success. Cases have fallen from 13,500 in 2010 to 2719 in 2016. The Global Fund has provided enough mosquito nets and antimalarial drugs to see the country through the 2018 malaria season, says spokesperson Seth Faison, who is based in Geneva.
But TB remains a stubborn and worsening problem. A quarter-century ago, North Korea’s TB prevalence—around 50 cases per 100,000 people—was approximately one-third of South Korea’s. But after a severe, prolonged famine in the North in the mid-1990s, the TB bacterium spread rapidly among malnourished survivors. According to WHO, North Korea’s TB incidence, or number of new cases, per 100,000 people shot up from under 200 in 2000 to 513 in 2016 (global incidence in 2016 was 140). An MPH survey carried out in 2015 and 2016—which outside experts laud for its rigor—pegged North Korea’s TB prevalence, or total cases, at 640 per 100,000 people.
Most North Korean TB patients now under medical care are taking drugs purchased under Global Fund grants. The Eugene Bell Foundation is providing drugs to treat about 1200 North Koreans with multidrug resistant (MDR) TB each year. That represents about 10% to 15% of each year’s new MDR cases, Seung says. MPH had proposed carrying out a drug-resistance survey in the next tranche of money from the Global Fund, he says, but that won’t happen now.
In announcing its decision last February to end grants to the Democratic People’s Republic of Korea (DPRK)the Global Fund cited its concern that the country’s “unique operating environment” prevented the group from providing “the required level of assurance and risk management” for its grants. Humanitarian groups and medical researchers criticized the decision in letters to The Lancet and in other forums. They implored the Global Fund to reconsider, noting that transparency concerns and challenging operating environments exist in many countries with high TB burdens. The Global Fund “has not modified its decision” to close the grants, Faison says. However, he says, “We hope to re-engage with DPRK when the operating environment allows the access and oversight required.”
Still, “the public outcry did have an effect,” Park says. The Global Fund recently agreed to allow leftover funds from its North Korea grants to be spent on a buffer stock of medications and diagnostics “sufficient to provide for continued treatment for TB patients [through] June 2019,” Faison says. There appear to be enough drugs on hand not only to treat existing patients, but also to enroll new patients through December, Park says. “The hope is that will buy enough time” to find a successor to the Global Fund, says Heidi Linton, executive director of Christian Friends of Korea, a nonprofit in Black Mountain, North Carolina, that a few years ago helped establish a National Tuberculosis Reference Laboratory in Pyongyang.
That won’t be easy, Seung says. “TB is a tough sell. It’s complex and messy, and makes donors tired.” He and observers hope the South Korean government will step in, if only to prevent TB—especially MDR strains—from spilling across the border.
One observer—a humanitarian worker who has discussed the issue privately with Global Fund officials—suggests the fund’s pullout is tactical. Closing the grants, he says, may give the fund leverage to negotiate access to more clinics in North Korea where TB drugs are dispensed, and on shorter notice. The expiring grants stipulate access to 70% of clinics on 4 days’ notice; the Global Fund, he says, has been pushing for access to all clinics on as short as 1 day’s notice.
In the meantime, humanitarian groups are bracing for tough times as international sanctions take an increasing toll. Many North Koreans “are struggling to make ends meet,” says Linton, who spends several weeks a year on the ground there. Malnutrition and a lack of access to clean water in many villages continue to make people vulnerable to TB, she says. The areas of North Korea that are most affected by TB “are disproportionately those without electricity, without access to health care, and most in need of assistance,” says Taehoon Kim, co-founder of DoDaum, a nonprofit in New York City with health programs in North Korea. North Korea’s public health system “will be tested more and more in the coming years,” he says. In the wake of the Global Fund’s pullout, Kim says, “I’m gravely concerned about whether it will be able to respond.”