Engaging North Korea on Mutual Interests in Tuberculosis Control, by Sharon Perry, Heidi Linton,...

8/2/2019 Engaging North Korea on Mutual Interests in Tuberculosis Control, by Sharon Perry, Heidi Linton, Louise Gresham, a

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Korea Economic Institute

Volume 5

Academic Paper Series

Contents:

Foreign and Domestic Economies of North and

South Korea

The Markets of Pyongyang

Similar Policies, Dierent Outcomes: Two Decadesof Economic Reforms in North Korea and Cuba

KORUS FTA Compared with KOREA-EU FTA:

Why The Dierences?

Developing an International Financial Center to

Modernize the Korean Service Sector

Security Factors and Regional Impact on the

Korean Peninsula

Preparing for Change in North Korea:

Shifting Out of Neutral

Reviving the Korean Armistice: Building Future

Peace on Historical Precedents

Proactive Deterrence: The Challenge of Escalation

Control on the Korean Peninsula

Human and Nuclear Security Concerns on the

Korean Peninsula

Engaging North Korea on Mutual Interests in

Tuberculosis Control

2012 Nuclear Security Summit: The Korean Twist


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ON KOREA 2012:

ACADEMIC PAPER SERIESVolume 5


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5

Human and Nuclear Security

Concerns on the Korean Peninsula


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7

Engaging North Korea on Mutual

Interests in Tuberculosis Control

Sharon Perry, Heidi Linton, Louise Gresham, and Gary SchoolnikSharon Perry served as director of the Stanford DPRK TB Laboratory

Project from 2008 to 2011, and is a member of the Naonal Commiee

on North Korea. Heidi Linton is execuve director of Chrisan Friends

of Korea, Black Mountain, North Carolina; Louise Gresham is director

of the Global Health and Security Iniave, Nuclear Threat Iniave,

Washington, D.C.; and Gary Schoolnik is associate dean and professor of

medicine at Stanford University School of Medicine, Stanford, California.

Relaons on the Korean Peninsula are at their coolest level in more than 20

years. Since 2006, when the Democrac Peoples Republic of Korea (DPRK)

announced that it had restarted its nuclear facilies, the government has

challenged internaonal nonproliferaon treaes on several occasions.

The death of Kim Jong-il in December 2011 as well as plans for transfer

of leadership to his youngest son, Kim Jong-un, bring new complexies to

government relaons with the outside world. Following military incidentsin 2010 along the long-disputed Northern Limit Line in the Yellow Sea, the

North has reinforced its relaons with China while pulling back on negoaons

with the United States and its allies.1

The DPRK is a foreign policy conundrum. While the regimes nuclear

ambions remain at the forefront of internaonal security concerns,2

the world is painfully aware that this isolated and enigmac country of

24 million people is also plagued by crippling energy, food, and medicalshortages.3 Since the famines of the 1990s, rates of tuberculosis (TB), a

disease that exploits malnutrion and other condions that compromise

natural immunity, have risen dramacally and are now among the highest

in the world outside of sub-Saharan Africa, including more than triple the

rates in China and South Korea.4 From 1995 to 2003, the U.S. government

provided more than a billion dollars in food, energy, and medical assistance

to North Korea.5 Absent an impact of humanitarian eorts on broader

diplomac opportunies, internaonal humanitarian contribuons havefallen o dramacally in recent years even as the North Korean economy

connues to struggle. In the decade since the breakdown of the Agreed

Framework, it is increasingly apparent that policies tying economic aid to

nuclear disarmament are not working.6


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8 2012 Volume 5 n ON KOREA

In this paper, we describe our experience working with the civilian DPRK

Ministry of Public Health (MoPH) to develop the countrys rst modern

TB laboratory.7 Begun in 2008, this unique collaboraon of U.S.-based

voluntary interests, including a major medical instuon, a humanitarian

nongovernmental organizaon (NGO), and a nonprot sponsor, has

achieved cooperaon on a crical public health objecve during a period

otherwise marked by profound deterioraon of relaons with the United

States and its allies in East Asia. Because coordinated global eorts are

needed to control TB in the anbioc era, we argue such engagements can

encourage broader assimilaon within the internaonal health community.

We rst provide background on the modern history of TB epidemics,

the new challenges to global health security posed by the emergence of

drug-resistant strains, and how these epidemics can interact with major

geopolical events. We hypothesize that the TB situaon in North Korea

today bears ominous parallels with condions accompanying the end

of the Cold War in Europe and that Northeast Asia faces a similar set of

challenges as it contemplates opportunies for assimilaon. We then describe

the process of implemenng the laboratory project and our objectives for

sustaining this effort. We conclude by discussing implications of these

efforts for North Korea and global health security interests.

Tuberculosis and Health

M. tuberculosis, the cause of human tuberculosis, is an airborne pathogen

that chronically infects more than one-third of the worlds populaon,

causing more than nine million cases of acve TB and nearly three million

deaths each year.8 Classically associated with condions of poverty,malnutrion, aging, and medical condions that suppress the immune

system, 80 percent of cases occur in the developing world. Because of

its inmate associaon with general health, parcularly in adults of

reproducve age, the World Bank and the World Health Organizaon

(WHO) have characterized TB control as one of the most cost-eecve

investments developing countries can make.9

A pathogen of humans for more than 50,000 years,10

M. tuberculosishas developed strategies for interacng with the human life span. The

natural history is characterized by three principal stages: exposure, latent

infecon, and acve disease with transmission to new hosts ENREF 5.11

Of those exposed to an infecous TB case, about 30 percent are thought

to develop the state of latent infecon, during which the host remains


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9Perry, Linton, Gresham, and Schoolnik: Engaging North Korea

healthy, but TB bacilli may survive for decades within clusters of immune

cells. Latent infecons constute the pathogens populaon reservoir.

Although the normal human immune system is substanally equipped

to control a latent infecon, in 10 percent of these infecons, the latent

state is terminated by a breakdown in immune defenses brought on by

malnutrion, illness, or aging, and the individual develops the acve,

contagious form of the disease. Without treatment, about 50 percent of

acve cases will die, and each infecous case at this stage will disseminate

the TB bacillus to 10 to 20 other persons.12 In this way, M. tuberculosis

is able to infect successive human generaons. In the pre-anbioc era,

TB epidemics could rage for centuries, devastang isolated populaons

weakened by hunger and acute infecons.13

Although anbiocs have greatly improved the treatment outcome

for TB, current therapy sll requires the combined use of at least four

dierent anbiocs administered in an uninterrupted manner for at least

six months.14 Because TB capitalizes on any condion that jeopardizes the

individuals general health, aenon to the paents nutrional status

and underlying medical condions is also required. The use of fewer

drugs, interrupon of drug therapy, inadequate nutrion or intervening

illness can result in poor clinical outcome (including death) and the

disseminaon of TB to other persons. For these reasons, control of

TB requires primary-care approaches and raonal drug management

strategies, including sustainable, stable, public health structures.

Drug-Resistant Tuberculosis

The discovery of curave drugs in the middle of the 20th century,including their applicaon to massive global public health campaigns,

came at a crical me in the polical realignment of the postwar world

and the emergence of modern global markets. These developments have

fundamentally altered the course of TB epidemics, parcularly in the

West. For example, rates of TB in the United States today are 3.6 per

100,000 populaon (compared with a global average of 137 per 100,000

in 200915) compared with 53 per 100,000 in 1953 when the rst an-TB

drugs were introduced.16

By the late 20th century, howeverwithin the short span of one human

generaontwo developments began to threaten these gains. The rst,

during the 1980s, was the emergence of AIDS, a disease that aacks the


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same immune cells required to control a latent TB infecon. The AIDS

epidemic has had a profound impact on TB trends, parcularly in Africa

where up to 30 percent of new TB cases may be due to HIV co-infecon.17

The second development was the emergence of muldrug-resistant

strains of TB (MDR TB), rst reported in the early 1990s.18

MDR TBdened as resistance to at least isoniazid and rifampicin, the two

most powerful front-line TB drugsaccounted for nearly a half million cases

of TB annually, including an esmated 150,000 deaths, in 2008.19 Treatment

of MDR TB requires up to two years of complex drug management with

regimens that oen have toxic side eects and are 50200 mes more

costly than drugs needed to treat persons with TB caused by drug-sensive

strains.20 Although survival rates are improving, they are only marginallybeer than those of the pre-drug era. Cases of extensively drug resistant

TB (XDR TB), dened by resistance to the major rst- and second-line TB

drugs and largely incurable, have now been reported in 58 countries with

the laboratory capacity to test for it, and it may account for up to 10 percent

of MDR TB cases globally.21 These trends raise the specter of an era in which

current drugs are no longer eecve.

Resistance to TB drugs arises from spontaneous mutaons in the TB ge-nome under drug selecon pressure, condions that are associated with

sporadic drug use, including poor paent adherence, as well as use of un-

regulated drug supplies. In this regard, drug-resistant TB is a preventable

man-made phenomenon. Drug mutaons develop rapidly in the seng of

monotherapy (use of only one drug for treatment) and will amplify quickly

to aect remaining drugs in the armamentarium.22 For this reason, com-

pared with new TB paents, risk of MDR TB is about 5.5 mes greater in

paents who have received inadequate therapy in the past.23 Because MDR

TB may develop over months or years, inadequately treated persons who

connue to be infecous can spread drug-resistant strains to persons in

their communies.24 If inadequately treated persons migrate across fron-

ers, drug-resistant strains can be spread to other populaons.

In absolute numbers, about 50 percent of MDR TB cases occur in China

and India although the highest proporons of TB cases with MDR (9 per-

cent of the worlds cases) reside in eastern Europe and Central Asia.25 Asmany as 50 percent of cases in countries of the former Soviet Union are

resistant to at least one TB drug.26 In parts of the Russian Federaon and

the countries of Kazakhstan, Tajikistan, Uzbekistan, and the Republic of

Moldova, 25 percent of new TB paents and more than 50 percent of


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previously treated paents suer from muldrug-resistant disease.27 The

age of these vicms peaks in young adulthood, suggesng a relavely

recent introducon.28 Muldrug-resistant strains may have been ampli-

ed by prolonged drug shortages that occurred during the period of eco-

nomic destabilizaon accompanying the collapse of the Soviet bloc in the

1980s.29 With the end of the Cold War in Europe, drug-resistant strains from

this epicenter have now been tracked by molecular ngerprinng methods

to North America, Europe, the Middle East, and even to South Africa.30

The magnitude and disseminaon of the MDR epidemic in the Eurasian

region and South Africa caught the world o guard and caused a reevalu-

aon of global strategies for TB control. Laboratories with capacity to test

for drug resistance were not available in most high-burden countries,31

and it was quickly recognized that the cost of treang MDR and XDR far ex-

ceeds public health budgets of developing countries.32 Since 2000, massive

resources have been organized through the STOP TB Partnership (www.

stoptb.org) to manage MDR and XDR TB and control its spread. A major

driver in the MDR TB scale-up eort has been the Global Fund to Fight

AIDS, Tuberculosis and Malaria (Global Fund), which in 2011 contributed

$700 million to global MDR TB control.33 Global Fund works closely with the

Green Light Commiee, which recommends standards for MDR TB care,34

and the Global Laboratory Iniave, which sets quality assurance standards

for drug suscepbility tesng and works to accelerate access to modern

TB diagnoscs.35 With addional support from programs like the Presi-

dents Emergency Plan for AIDS Relief (PEPFAR), the Obama Global Health

Iniave, UNITAID, and the Foundaon for Innovave Diagnoscs

(FIND), 27 high-burden MDR TB countries15 of which were states of the

former Soviet blochave been targeted for aggressive scale-up operaons.36

The Soviet experience shows that drug-resistant strains of TB, generated

in one region as a consequence of failed public health programs, can

disseminate to spawn outbreaks of drug-resistant disease both regionally

and remotely. This experience also reminds us that MDR epidemics leave

costly legacies for which the world community is ulmately responsible.

We contend that polical and economic condions coinciding with the

emergence of new drug-resistant strains in the former Soviet Union sll

persist in Northeast Asia.

Perry, Linton, Gresham, and Schoolnik: Engaging North Korea


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Tuberculosis in North Korea

Health System

TB care in North Korea was heavily inuenced by the Soviet model of

centralized administraon and sanatorium care. During the 1960s and1970s when Soviet bloc subsidies were plenful, North Korea implemented

a universal health care program (Arcle 72 of the Constuon), and

developed its household doctor system. At a reported coverage of 1

doctor per 134 households, this system boasts one of highest coverage

raos in Asia even today.37 During this period, the No. 3 (TB) Prevenon

Department of the MoPH built a mulered residenal treatment system

for TB with its own pharmaceucal industry, including 10 provincial TB

hospitals as well as a system of 6070 bed TB rest homes in each of the

countrys approximately 225 counes and municipal districts.38

Since the loss of Soviet aid in the 1990s,39 much of the public health

infrastructure, including physical plant and medical equipment, has

not been updated, and the TB pharmaceucal industry has virtually

disappeared. Although the health system remains largely intact

organizaonally, chronic energy, equipment, and supply shortages plague

operaons at every level. Today the country relies almost enrely ona dwindling supply of donors for basic medical supplies, including TB

drugs and diagnoscs. The DPRK is not eligible for basic health sector

development funds, such as through the World Bank, Internaonal

Monetary Fund, or the Asia Development Bank.

Epidemiologic Trends

In 1998, WHO established a country oce in Pyongyang.40 This program,

which is supported by connuing cooperave planning agreementsbetween the WHO and the government, provides one source of

documentaon of health trends inside the DPRK. These and other

planning documents make it clear that the famines of the mid-1990s

had a profound impact on the general health status of the populaon,

including rates of infant and maternal mortality, hepas, malaria, and

TB.41 From 1996 to 1999, rates of mortality due to TB tripled to more

than 100 per 100,000 populaon, rivaling some of the worst rates in the

developing world.42 Average caloric intake in DPRK has steadily declinedover the past 20 years and is the lowest in the Asia-Pacic region; North

Koreas current caloric intake per person is less than two-thirds of that of

China and the ROK.43 The Organizaon for Economic Development (OECD)

esmated that 32 percent of the populaon was malnourished in 2006,


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and a survey jointly sponsored in 2009 by the World Food Program, Food

and Agriculture Organizaon, and UNICEF esmated that 32 percent of

children are of stunted height, 18 percent underweight, and 5 percent of

low weight for height.44 A new United Naons census released in 2010

esmates that life expectancy has declined by 3.4 years (to 69.3 years)since 1993, while infant and maternal mortality rates, each among the

highest in the Asia-Pacic region, have risen 36 percent and 46 percent,

respecvely, in the same period.45

TB caseload esmates provided to WHO by the MoPH for 1994, the period

just before the great famines, show a TB incidence rate of about 38 per

100,000 populaon.46 Although these gures pre-date the development of

standardized reporng systems, such rates are similar to those reportedin other Soviet-style systems of the era and would be in a range reported

by middle-income countries today. In 2001, MoPH adopted the WHO-

sponsored Directly Observed Short Course Therapy (DOTS) program for TB

control, including its treatment standards and reporng formats.47 In 2006,

three years aer this program was implemented naonwide, an incidence

rate of 178 per 100,000 was reported.48 In 2009, following a small community

infecon survey,49 WHO doubled its esmates of TB incidence to 345 per

100,000 populaon.50 For 2010, North Korea is expected to require drugsfor nearly 100,000 TB paents, translang to a case rate more than 370 per

100,000 populaon.51 Compared with the 22 historically designated high-

burden countries,52 TB incidence in North Korea ranks number seven or

number eight in the world, being one of the highest outside of sub-Saharan

Africa and nearly four mes the rates in China (78 per 100,000) and South

Korea (97 per 100,000) in 2010 (Figure 1).53 These trends are not due to

poor program performance, as DPRK maintains very high case detecon

and treatment compleon rates within the WHO DOTS program.54



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DPRK ROK China Mongolia

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

400

350

300

250

200

150

100

50

0

Figure 1: Trends in Incidence of Tuberculosis in East Asia,

19902010

Source: WHO, Global Tuberculosis Control 2011 (Geneva: World Health Organizaon, 2011),Annex 3.Age-specic case trends and an annual risk of TB infecon esmated at 3.2 percent

suggest the epidemic is sll expanding (at perhaps 10 percent per year),55

plausibly fannedby connuing food shortages and acute infecons such as measles that are known tosuppress the immune system.56

TB Assistance to North Korea

As a low-income country (less than $1,000 annual income per capita) with

a TB incidence rate in excess of 100 per 100,000, the DPRK meets high-

priority condions for assistance through the world STOP TB partnership

of funds. From 2001 through 2007, the country received basic TB drugsand diagnosc supplies through the WHO-sponsored Global Drug Facility

(GDF). However, the adequacy and sustainability of this assistance, oen

supplemented by NGO donaons,57 have been complicated by the countrys

diplomac isolaon. In 2003 and 2006, for example, the country lost bids

to qualify for longer-term TB assistance through the Global Fund. Following

the nuclear test in 2006, a $400,000 grant from the Canadian Internaonal

Development Agency (CIDA) to WHO for expansion of TB programs in the

DPRK was withdrawn.58 In 2010, following two exceponal years of bridgefunding through GDF and WHO regional budgets, the Global Fund reached

an agreement with the DPRK that is expected to connue rst-line TB

medicines for at least another two years and also enable planning for MDR

TB surveys and treatment programs. Because the DPRK is subject to the

Global Funds addional safeguards policies, UNICEF has been appointed


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principal recipient for the countrys TB and malaria grants.59 Because of

recent shoralls in Global Fund accounts, funds for the connuaon phase

of this grant are likely to be subject to signicant cuts.60

As a result of this problemac funding history, crical capacity needs ofthe DPRK naonal TB program have been postponed even as the countrys

epidemic has connued to expand. The precise magnitude of this epidemic

is uncertain, however, because published epidemiologic data may dier

from stascs heard by NGOs on the ground, and Web resources oen

present diering esmates. In addion to basic energy and nutrional needs

not covered by standard TB program assistance, one of the most crical of

the postponed agendas has been development of resources to diagnose

and treat drug resistance. Unl iniaon of the U.S.-DPRK TuberculosisProject, the DPRK naonal TB program was one of the few operang in

a country with a TB incidence rate over 300 per 100,000 populaon that

lacked funding for development of at least one facility for diagnosis of TB

by culture and drug suscepbility tesng. In the absence of such facilies,

the contribuon of drug resistance to this epidemic, including the types

of drugs needed to treat paents who fail to respond to standard therapy,

cannot be determined. Although the DPRK is not a candidate for the global

MDR scale-up eort targeted to high-burden countries, rates of drug

resistance are likely to be signicant, a predicon based on retreatment

rates reported to WHO as well as regional trends.61

Regional Implicaons

The DPRKs TB epidemic has important implicaons for Northeast Asia,

including provinces of northeast China, Mongolia, and neighboring oblasts

of the Russian Federaon. Rates of drug resistance in Northeast Asia

are some of the highest in the world outside of the Russian Federaon,with which the area shares extensive borders. In 2008, the China

Center for Disease Control reported that rates of drug resistance in the

northeastern provinces of Inner Mongolia Autonomous Region, Liaoning,

and Heilongjiang exceeded 7 percent among new cases of TB and ranged

from 24 percent to 37 percent among previously treated cases. A small

naonwide survey carried out in Mongolia during 1999 found rates of

isoniazid mono-resistance to be as high as 30 percent, although rates of

muldrug resistance may be lower than in neighboring areas owing to therelavely late introducon of rifampicin in that country.63

High background rates of MDR TB, especially among previously treated

paents in this region, may be due to shared historical circumstances. Public

health systems in this part of the world are sll recovering economically



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from the breakup of the communist bloc. Older, sanatorium-style systems

of TB care are common, and much of the laboratory infrastructure requires

upgrading.64 Many countries in the region have experienced unprecedented

prosperity and are just beginning to launch MDR scale-up programs.

Although more than one-half of the worlds MDR burden occurs in China,

India, and other parts of East and Southeast Asia,65 less than 4 percent

of these cases have been been enrolled in treatment programs to date.66

Compared with 12 in the European region,67 there are only three cered

supranaonal TB reference laboratories (in Chennai, Bangkok, and Hong

Kong) serving the enrety of connental Asia. South Koreas supranaonal

TB reference laboratory, a designated training center in the internaonal

reference and research system, is inaccessible to North Korea. In short,

because of the constraints of Cold War relaons, this region is poorly

prepared to respond to a collapse of TB care on or within its borders. For

this reason, the response to the DPRK TB epidemic must also be looked at

in the context of supporng an important health security agenda for an

epidemiologically vulnerable region of the world.

In summary, the TB epidemic in the DPRK has evolved ominously since

the breakup of the Soviet Union and the famines of the 1990s. In contrast

with the Soviet experience, and in part in response to it, the global healthcommunity is far beer organized today to ensure that no country,

regardless of its polical system, goes without basic TB drugs. At the same

me, because of connuing diplomac isolaon, the country remains o

the radar for internaonally funded MDR scale-up programs. This should

be seen as an urgent regional priority.

The U.S.-DPRK Tuberculosis Project

Goals

The goals of the U.S.-DPRK Tuberculosis Project are to develop sustainable

professional and academic collaboraons with the North Korean Ministry

of Public Health focused on mutual interests in TB control and to facilitate

networking with other TB programs in the region and internaonally.

History

The concept for this project arose indirectly from unocial discussionsaending the so-called track 2 arm of the six-party talks. In February of

2007, during the h round of the six-party talks, the DPRK agreed to

phase out the Yongbyon nuclear plant in exchange for economic assistance

and eventual normalizaon of relaons.68 Working with this framework,

Stanford professor of polical science, John W. Lewis, solicited School


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of Medicine colleagues to assess the prospects of engagement focused

on mutual interests in TB control. Following these discussions, Lewis

obtained approvals for a delegaon of DPRK public health ocials to

meet with TB specialists at Stanford. In January 2008, with sponsorship

from the Freeman-Spogli Instutes Center for Internaonal Security and

Cooperaon (CISAC) and Walter H. Shorenstein Asia-Pacic Research

Center (APARC), four DPRK MoPH ocials and one protocol ocer spent

a week in northern California, touring TB facilies in the San Francisco

Bay Area (Figure 2). The Bay Area TB Consorum (Stanford/BATC), an

aliaon of TB physicians, microbiologists, and epidemiologists drawn

from the areas medical schools and public health departments, was

organized by Stanford School of Medicine to host the delegaon along

with ex ocio representaves from the Korea Society, Eli Lilly Foundaon,

the U.S. Centers for Disease Control and Prevenon (CDC), and WHO.

Figure 2: MoPH

Delegaon at

Stanford University,

12 January 2008

During these discus-

sions, MoPH repre-sentaves, led by

the director general

of the No. 2 and No.

3 (TB and Hepa-

s) Departments,

requested assistance

to complete a modern TB reference laboratory at the campus of the No. 3

(TB) Prevenon Hospital in the capital city of Pyongyang. Although WHO

and MoPH had devised a site plan and equipment inventory for this project

in 2006, the iniave had since stalled for lack of funds.69

Implementaon

From this seminal meeng at Stanford, the U.S.-DPRK Tuberculosis Project

evolved into the partnership of the Stanford Bay Area TB Consorum, the

Nuclear Threat Iniave/Global Health and Security Iniave (NTI/Global

Health and Security Iniave), and Chrisan Friends of Korea. Since 2009,these organizaons have contributed a combined total of more than

$600,000 and have completed more than 12 in-country visits to develop the

DPRKs rst modern TB laboratory. Despite signicant diplomac reversals

coinciding with our schedule, momentum was not aected, and U.S. teams



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2008

MOPH visit

to Stanford

2008

CFK on-site visit

2009Deliveries &

Installaons

2010

Dedicaon

Ceremony

2010-Present

BATC Training

Workshops

U.S. food program ends

Missile Test, Nuclear Test

Choenan Incident

Yeongpyong Island Incident

experienced extraordinary cooperaon from MoPH and other government

ocials. Implementaon of the project has progressed through four

principal stages, including organizaonal development, site assessments,

installaons, and technical training (Figure 3).

Figure 3: U.S.-DPRK Tuberculosis Project Implementaon Schedule

Source: Authors concept.

Organizaonal development (March 2008December 2008).

Shortly aer the meeng at Stanford, organizers obtained the proposed

TB laboratory inventory from WHO representaves in Pyongyang and,

with assistance of Dr. Gail Cassell of the Eli Lilly Foundaon, successfully

applied to the NTI/Global Health and Security Iniave of the Nuclear

Threat Iniave for funds to carry out site assessments and purchase

the recommended equipment and supplies. During this phase, Stanford

organizers also iniated contacts with the U.S.-DPRK NGO community

and established ongoing working relaons with world health ocials in

Pyongyang, New Delhi, and Geneva to ensure that laboratory donaons

conformed to internaonal standards and plans for the DPRK. In October

2008, Chrisan Friends of Korea (CFK), a U.S. NGO with more than 15 years

of experience provisioning and renovang TB facilies in North and South

Hwanghae provinces, was able to visit the proposed laboratory site during

one of its regular in-country technical missions. CFK developed a physical

infrastructure report, idenfying an addional budget for infrastructurerenovaons, including plumbing and electricaon, needed to support the

proposed Stanford and NTI equipment donaons.


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19

On the basis of these assessments, in December 2008, Stanford and

CFK approached the DPRKs mission to the United Naons in New York

to propose a joint undertaking. Under this plan, CFK agreed to organize

logiscs and in-country visits, secure necessary U.S. export licenses,

and complete physical renovaons in cooperaon with MoPH and local

hospital sta. Stanford/BATC agreed to assess TB laboratory technology

needs, procure the TB laboratory inventory in collaboraon with its

funding sponsor, and organize in-country expert training workshops.

Thus, the project built upon a previously established foundaon in U.S.-

DPRK NGO relaons and evolved to combine a strong mix of U.S.-based

scienc, humanitarian, and health policy experse in TB control.

On-site assessments (April 2009September 2009).Following MoPH acceptance of this proposal, joint Stanford/CFK site

assessment teams visited the laboratory site in May and August of 2009

(Figure 4) to develop work plans and procurement specicaons in

consultaon with MoPH and WHO representaves. Technical experse

on the assessment teams included a construcon engineer, a biomedical

engineer, and a clinical laboratory consultant from CFK and, on behalf of the

Stanford/BATC, a supervising scienst from a TB public health laboratory in

California and a TB epidemiologist from Stanford School of Medicine. Three

coordinators from the MoPHs Department of External Aairs were assigned

to facilitate in-country delegaons during the rst on-site assessment visit,

and they have remained invaluable partners of the project ever since.

Figure 4: Site Plan-

ning Visit, May 2009

Based on these site

assessments, licenseapplicaons for reno-

vaon materials and

laboratory supplies

were submied to

the Bureau of Indus-

try and Security of

the U.S. Department

of Commerce. Fol-

lowing approvals in

the summer of 2009, procurements were completed and prepared for

shipment during September 2009.



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Delivery and installaon (November 2009October 2010).

From 29 October to 24 November 2009, a 22-member revolving delegaon,

including CFK and Stanford/BATC work teams and a representave from

the NTI/Global Health and Security Iniave, spent nearly a month working

at the laboratory site in Pyongyang. Scores of MoPH personnel (including lab

sta, doctors, nursing students, and volunteers) worked side by side with

skilled CFK volunteer construcon teams to remodel rooms, install electrical

and plumbing systems, and build workbench spaces (Figure 5). A CFK

bioengineer together with a team of Stanford/BATC laboratory trainers and

MoPH laboratory physicians installed and tested several pieces of equipment.

Two addional visits in May and August of 2010 were required to complete

the renovaons and verify inventory. During the summer of 2010, CFK raisedaddional funds and oversaw the installaon of a four-kilometer dedicated

high voltage cable connecng the laboratory to the municipal power supply.

Figure 5: CFK and MoPH Work

Crews Threading New Electrical

Lines, November 2009

With physical plant installaons

completed, DPRKs rst TB lab-

oratory designed to perform

reference-level quality assurance,

culture, and drug-suscepbility

tesng was formally dedicated

on 18 October 2010 in a ceremony

hosted by the vice minister of the

Ministry of Public Health. In addion to representaves from Stanford/

BATC and CFK, ocials from the WHO Pyongyang oce, UNICEF (thenew Global Fund agent for the DPRK), and sta from the No. 3 (TB)

hospital campus were in aendance.

Training and technical assistance programs (November 2010present).

The Stanford/BATC team includes public health laboratory specialists

from the state of Californias TB laboratory system, the Stanford Hospitals

Clinical Microbiology Laboratory, and infecous disease faculty from the

Stanford School of Medicine, as well as outside consultants. Individual

members of this group have extensive experience in internaonal health,

including service on WHO and CDC working commiees, and on advisory

panels of country-based infecous disease control programs.


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21

Figure 6: Naonal

Tuberculosis Refer-

ence Laboratory,

Joint BayArea TB

Consorum-MoPHTraining Workshop,

October 2010

This team is comple-

mented by CFK pro-

fessional volunteers,

including a clinical

laboratory professor,

a bioengineer with extensive experience in internaonal sengs, and

a rered clinical microbiologist uent in Korean. Since November 2009,

these teams, in collaboraon with MoPH physicians and laboratory

technicians, have been conducng orientaon and training workshops

covering basic safety procedures, inventory maintenance, and standard

operang procedures for culture and drug suscepbility tesng (Figure

6). The project also seeks to foster regional aliaons for TB control and

in April 2011 sponsored a visit by seven MoPH ocials to the ShanghaiCenters for Disease Control. Addional workshops and training exchanges

are planned through 2012.

Future of the Project

Located within the No. 3 (TB) Prevenon Hospital, DPRKs new naonal

TB reference laboratory is a 2,500-square-foot facility, including 13 rooms

modeled and equipped to internaonal laboratory standards and a

dedicated power supply to run incubators and other essenal equipment

on a 24-hour basis. The laboratory has a sta of 15 administrators,

physicians, and technicians. Three laboratory physicians have been

with the project since the meeng at Stanford in 2008. The laboratory

project has also served as a catalyst for addional investments in central

TB control. With the help of CFK, the Central TB Prevenve Instute in

Pyongyang, where the laboratory is housed, has since completed a state-

of-the-art operang room suite and installed three greenhouses for food

producon, with addional plans in 2012 to develop classroom facilies.

Role of the laboratory in tuberculosis control.

To prepare for its role in naonal TB control, the new reference laboratory

must undergo internaonal inspecons and parcipate in eld trials

designed to assure the reliability and quality of laboratory results.

Ulmately, the plan is to develop capacity to test several thousand



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cases of suspected MDR TB per year. The laboratory is also expected

to develop capacity to provide surveillance for the naonal TB control

program, determine prevalence of drug resistance in North Korea,70

and guide treatment in paents suspected of having drug resistance.71

By oering modern, reference-level diagnosc and clinical consultaon

services, the laboratory can also serve as a naonal resource or center of

TB excellence for physicians, laboratorians, and medical and laboratory

trainees throughout the country. This resource can also help integrate TB

care provided by other ministries into the MoPH DOTS program.

We believe these goals are feasible over the next two to three years,

parcularly if MoPH is able to build academic collaboraons with scienc

teams such as the BATC and develop aliaons with internaonal laboratoryand medical organizaons. The high literacy rate in the DPRK and the

competencies observed by the BATC training team also suggest that MoPH

possesses the human capital needed to realize these goals. The project

is currently working with the WHO country oce to assess connuing

training needs in order to strengthen qualicaons for internaonal

accreditaon and create opportunies for collaborave research on MDR

TB with academic instuons in the region as well as abroad.

Factors contribung to success.

The momentum of this project has depended on several interrelated

factors. First, from a polical perspecve, the project beneted from the

iniave of policy specialists at the outset to recognize an opportunity

for health engagement during a period when work toward normalizaon

of relaons with the United States seemed possible. Second, the project

addresses a public health priority (TB control) that is recognized at the

highest levels of the DPRK government. The experse assembled through

the Bay Area TB Consorum and eorts to involve world health authories

in planning are important as MoPH moves toward qualicaons for

broader internaonal support. Third, NTI/Global Health and Securitys

prior work building cooperaon across disputed borders and recognion

of the need for cooperave disease surveillance72 led to crical funding

support for laboratory donaons. Having this funding secured at an early

stage of planning helped greatly to spur the organizaonal partnerships

needed to implement the project. Fourth, the preexistence of a highly

valued NGO relaonship with CFK, including CFKs reputaon for trust

building, follow-through, and sincere humanitarian focus, was a crical

factor in gaining acceptance from government ocials on both sides of

the Pacic. Fih, academic instuons must be prepared to ancipate


23/31

23

signicant infrastructure needs in the DPRK that are precedent to building

producve program collaboraons. Thus, partnering with CFK also brought

important experience and capacity to address crical renovaon and

electrical power needs associated with TB programs in the DPRK. Finally,

the connuity of personnel on both sides enabled an atmosphere of mutual

understanding and focused persistence to ourish.

Many challenges along the waysuch as delivery delays, freezing

temperatures, retrong problems, sickness on the work teams, and

the need to improvise training condions in the early stagescould

have derailed the iniave. These were overcome cheerfully and in

good faith and have contributed to strengthening es between the U.S.

and DPRK teams. At the same me, the next stage of this projecttosupport accreditaon of the laboratory through training partnerships

and operaonal research collaboraonis crical to establishing the

sustainability of our eorts and the potenal for this unique U.S.-DPRK

cooperaon to have a meaningful impact on TB trends in the DPRK.

Implications

The modern history of TB epidemics, including emergence of HIV

and MDR TB in the second half of the 20th century, has taught us that

professional and economic isolaon are dangerous co-conspirators.

Control of TB in the anbioc era requires coordinated internaonal

approaches to upgrade laboratory infrastructure, manage global drug

supplies, and support research for new diagnoscs, drugs, and vaccines.

Academic collaboraons with the DPRK focused on TB research and control

oer important, ideologically neutral opportunies for assimilaon withinthe internaonal health and related scienc research community. Through

the World STOP TB partnership, the American-Thoracic Society, the U.S.

CDC, and the Internaonal Union against Tuberculosis and Lung Disease,

the internaonal TB professional community has developed an extensive

global network of training, consultancy, and quality assessment resources.

Providing opportunies for North Korean public health ocials to link to

this dynamic pedagogic community should be a priority.

The establishment of a reference-level naonal TB laboratory in the DPRK

also begins to address an important blind spot in TB control for Northeast

Asia. The laboratory can serve as a basis to foster new professional relaons

applied to regional disease surveillance, infrastructure development,

innovave professional pracces, and other technical assistance exchanges.



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Regional partnerships, such as the Middle East Consorum on Infecous

Disease Surveillance and the Mekong Basin Disease Surveillance Network,

show that such engagements are possible despite the lack of diplomac

relaons among member countries.73 Other regions of the world that

would benet from regional planning for TB control include the Eurasian arc

encompassing Afghanistan to Pakistan, India, and the southern republics of

the former Soviet Union, and the cluster of countries in Southeast Asia.

For polical reasons similar to those aecng Northeast Asia, countries in

these clusters report to dierent WHO regional headquarters.

In contrast with the situaon 25 years ago, the world is in a far beer posion

today to recognize the risks of MDR TB epidemics where food and TB drug

shortages persist. Although substanal resources are now available to respondto MDR TB hot spots, the TB epidemic in North Korea illustrates that these

mechanisms sll do not work well in non-treaty areaswhere, nonetheless,

they may be most needed. First, in regions isolated by conict, epidemiologic

trends are oen dicult to track or the documentaon simply does not

exist. Second, high-level polical agreements needed to engage in regional

planning and to implement crical assistance programs may not be possible.

Third, food, immunizaon, and energy shortages, typically not embraced

as TB program assistance, are part of weakened public health systems and

need to be addressed by internaonal TB response systems. Finally, policy,

humanitarian, and medical communies need to work creavely together to

structure the opportunies that lead to construcve, sustained engagement

in areas isolated by conict. For these reasons, private iniaves such as ours

remain vital to extend the froners of global TB control eorts.

Our project worked within an exisng bureaucrac structure that is unique

to the history of TB assistance for the DPRK. For these eorts to translateinto broader engagement opportunies for U.S. academic instuons,

addional educaon is needed. At the present me, the primary point of

access for university engagement is through the Korean-American Private

Exchange Society (KAPES), a self-described nonprot North Korean enty

established in 2005 and charged with managing U.S.-based humanitarian

and academic relaonships. This structure faces limitaons in introducing

the extraordinary range of intellectual resources that U.S. universies can

bring to academic collaboraons with North Korean sciensts.74 Recent

eorts like the U.S.-DPRK Scienc Exchange Consorum75 are important

not only to educate North Korea about the organizaon of higher educaon

and research in the United States but also to promote a coordinated

approach to academic engagement on the U.S. side.


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25

Summary and Conclusions

Historically, health assistance has been relegated to the role of humanitarian

eort and has occupied a subordinate role in foreign policy. With globalizaon

and the emergence of shared threats such as HIV, MDR TB, avian inuenza,and bioterrorism, health and security policy are increasingly connected.76

As one of the last outposts of Cold War polics,77 the 60-year-old Korean

conict challenges us to recognize this connecon. While media coverage

of North Korea remains dominated by convenonal security concerns, U.S.

cizens, including more than two million ethnic Koreans, are increasingly

aware of the economic rigors faced by the North Korean people.78

As some observers are suggesng,79

economic sancons intended to inducethe DPRK to abandon its nuclear weapons programs may be untenable

from both security and humanitarian perspecves. In this view, by greatly

discouraging foreign private sector parcipaon, economic sancons have

had the unintended eect of exacerbang a public health crisis in the DPRK.

Tuberculosis trends, a barometer that touches every aspect of human

health, illustrate the deadly externalies of this approach. Our experience

shows that construcve health engagements with the DPRK are possible

despite diplomac reversals at the state-to-state level. A review of sanconspolicies with the aim of facilitang broader public health engagements, like

the U.S.-DPRK Tuberculosis Project, is urgently needed for humanitarian

reasons. In the longer term, expanded public health exchanges may also

contribute to the reducon of tensions on the Korean Peninsula and a

posive evoluon of relaons with the DPRK.

Sharon Perry served as director of the Stanford DPRK TB Laboratory Project

from 2008 to 2011, and is a member of the Naonal Commiee on NorthKorea. Gary Schoolnik is associate dean and professor of medicine at Stanford

University School of Medicine, Stanford, California; Heidi Linton is execuve

director of Chrisan Friends of Korea, Black Mountain, North Carolina; and

Louise Gresham is director of the Global Health and Security Iniave,

Nuclear Threat Iniave, Washington, D.C.

The authors gratefully acknowledge the Stanford/BATC laboratory advisory

and training teams, including Dr. Ed Desmond, Dr. Niaz Banaei, Ms. Grace Lin,

Ms. Linda Kuo, Dr. Robert Luo, and Dr. James MacLaughlin as well as CFK clinical

laboratory expert Dr. Marcia Kilsby of Andrews University, CFK microbiologist

Dr. Choong Park, CFK construcon engineer Mr. Rob Robinson, CFK bioengineer

Mr. Mark Heydenburg, and more than a dozen skilled volunteer tradesmen. The

authors thank Mr. David Straub for his valuable comments on the manuscript.



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20 S. Keshavjee and P. E. Farmer, Picking Up the PaceScale-Up of MDR Tuberculosis

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21 WHO, Muldrug and Extensively Drug-Resistant TB (M/XDR-TB).

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24 Up to 10 percent of MDR cases are thought to aect children under the age of 15.Tuberculosis in a young child is both dicult to diagnose and a sennel of communitytransmission; see, for example, H. S. Schaaf, B. J. Marais, A. C. Hesseling, W. Brile, and

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25 Gandhi et al., Muldrug-Resistant and Extensively Drug-Resistant Tuberculosis.

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30 P. J. Bifani, B. Mathema, N. E. Kurepina, and B. N. Kreiswirth, Global Disseminaon ofthe Mycobacterium Tuberculosis W-Beijing Family Strains, Trends Microbiol10 (2002):

4552; I. Mokrousov et al., Origin and Primary Dispersal of the Mycobacterium Tuber-culosis Beijing Genotype: Clues from Human Phylogeography, Genome Research 15(2005): 135764; E. Lasunskaia et al., Emerging Muldrug Resistant MycobacteriumTuberculosis Strains of the Beijing Genotype Circulang in Russia Express a Paern ofBiological Properes Associated with Enhanced Virulence, Microbes Infect12 (2010):46775; J. R. Glynn, K. Kremer, M. P. Rodrigues, and D. van Soolingen, Beijing/W Gen-otype Mycobacterium tuberculosis and Drug Resistance, Emerging Infecous Diseases12 (2006): 73643; D. Cowley et al., Recent and Rapid Emergence of W-Beijing Strainsof Mycobacterium Tuberculosis in Cape Town, South Africa, Clin Infect Dis 47 (2008):125259; T. Kubica, S. Rusch-Gerdes, and S. Niemann, The Beijing Genotype Is Emerg-ing among Muldrug-Resistant Mycobacterium Tuberculosis Strains from Germany, Int

J Tuberc Lung Dis 8 (2004): 110713.31 P. M. Small and M. Pai, Tuberculosis DiagnosisTime for a Game Change, New

England Journal of Medicine 363 (2010): 107071.

32 Donald and van Helden, The Global Burden of Tuberculosis.

33 WHO, Muldrug and Extensively Drug-Resistant TB (M/XDR-TB), 2011.

34 R. Gupta et al., Increasing Transparency in Partnerships for HealthIntroducing theGreen Light Commiee, Trop Med Int Health 7 (2002): 97076.



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35 A. Laszlo, M. Rahman, M. Espinal, and M. Raviglione, Quality Assurance Programmefor Drug Suscepbility Tesng of Mycobacterium Tuberculosis in the WHO/IUATLDSupranaonal Reference Laboratory Network: Five Rounds of Prociency Tesng,19941998, Int J Tuberc Lung Dis 6 (2002): 74856.

36 S. Keshavjee and P. E. Farmer, Picking Up the Pace.

37 WHO, Health in Asia and the Pacic (New Delhi: WHO Regional Oce of Southeast Asia,2008); Organizaon for Economic Cooperaon and Development, Health at a Glance,Asia-Pacic 2010 (OECD, 2010); S. Perry, Health Care Infrastructure Challenges in DPRK(presentaon at USC-Center for Strategic and Internaonal Studies conference, August2011).

38 WHO, WHO Country Cooperaon Strategy, 20042008: Democrac Peoples Republicof North Korea (Pyongyang Oce and Geneva: World Health Organizaon, 2003). Otherministries, including the military, railways, and prisons, also operate health care systems.

39 R. Weitz, Russia and the Koreas: Past Policies and Future Possibilies, Academic PaperSeries on Korea (Korea Economic Instute) 5 (2010): 117.

40 As an arfact of the Korean conict, the DPRK is assigned to the South East Regionof WHO operaons headquartered in New Delhi, while South Korea (and also China)is assigned to the Western Pacic Region, headquartered in Manila.

41 WHO, WHO Country Cooperaon Strategy, 20042008; D. Goodkind and L. West, TheNorth Korean Famine and Its Demographic Impact, Populaon and Development Review(2001).

42 WHO, Global Tuberculosis Control: Country Data, World Health Organizaon,Geneva, 2010.

43 WHO, Health in Asia and the Pacic; OECD, Health at a Glance. Average caloric intake

for the Asia-Pacic region was esmated at 2500 k/cal in 2007 (Food and AgricultureOrganizaon, faostat.org, cited in OECD, Health at a Glance). The 2009 WFP/FAO/UNI-CEF Crop and Food Security Assessment used a baseline of 1640 k/cal for North Korea.

44 Instute of Children Nutrion, DPRK 2004 Nutrion Survey: Report of Survey Results(Pyongyang, DPRK, 2005).

45 North Koreans Life Expectancy Falls as Infant Mortality Rises, The Times (London),22 February 2010.

46 WHO, WHO Country Cooperaon Strategy, 20042008.

47 DOTS focuses on paent adherence to a course of treatment and is thus a strategicprevenon program for MDR TB.

48 WHO, DPRK: Country Prole, World Health Organizaon, Geneva, 2006.

49 WHO, The Regional Strategic Plan for Tuberculosis Control 20062015 (New Delhi:World Health Organizaon, Regional Oce for Southeast Asia, 2006).

50 WHO, Global Tuberculosis Control: Country Data; WHO, Democrac PeoplesRepublic of Korea: Tuberculosis Prole, 2009, www.who.int/tb/data.

51 Sarveshwar Puri, personal communicaon with author; meeng at WHO CountryOce with representaves of the U.S.-DPRK Tuberculosis Project, Pyongyang,25 April 2010.

52 WHO, Global Tuberculosis Control 2010.

53 WHO, Global Tuberculosis Control: Country Data.

54 WHO, DPRK: Country Prole, 2010.

55 WHO, The Regional Strategic Plan for Tuberculosis Control 20062015.

56 According to WHO Country Prole, 2009, HIV infecon is not considered a factorin the DPRK TB epidemic.


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29

57 Chrisan Friends of Korea and the Eugene Bell Foundaon have provided supplementaldrugs as well as food and agricultural and other supplies to TB facilies largely in thefour westernmost provinces of the DPRK since 1997.

58 WHO and MoPH ocials, personal communicaon to members of the Stanford/BATC,14 January 2008; U.S. food aid to the DPRK dropped to nothing in scal years 2006 and

2007, and in 2008 the United States terminated new shipments through the WorldFood Programme owing to disagreements over vericaon; see Foreign Assistance toNorth Korea (Washington, D.C.: Congressional Research Oce, 12 March 2010).

59 UNICEF, Strengthening Tuberculosis Control in DPR Korea, Global Fund to FightAIDS, Tuberculosis and Malaria, North Korea, 2010. In 2012, DPRK plans to apply fora connuaon of its Global Fund award through 2014; like many countries enteringconnuaon phase, cuts are expected owing to donor replenishment shoralls.

60 Ibid.

61 WHO, Global Tuberculosis Control; J. Parry, North Koreas Fight against TuberculosisGets a Boost, BMJ (Clinical research ed) 340 (2010): c2223.

62 G. X. He et al., Prevalence of Tuberculosis Drug Resistance in 10 Provinces of China,BMC Infecous Diseases 8 (2008): 166.

63 WHO, Muldrug and Extensively Drug-Resistant TB (M/XDR-TB); G. Tsogt et al., Na-onwide Tuberculosis Drug Resistance Survey in Mongolia, 1999, Int J Tuberc Lung Dis6 (2002): 28994.

64 G.X. He et al., Availability of Second-Line Drugs and An-Tuberculosis Drug SuscepbilityTesng in China: A Situaonal Analysis, Int J Tuberc Lung Dis 14 (2010): 88489.




68 E. Cody, Tentave Nuclear Deal Struck with North Korea, Washington Post, 13 Febru-ary 2007; J. W. Lewis and R. Carlin, What North Korea Really Wants, Washington Post,27 January 2007.

69 WHO, Regional Strategic Plan for Tuberculosis Control 20062015.

70 WHO, Guidelines for Surveillance of Drug Resistance in Tuberculosis, 4th ed. (Geneva: WorldHealth Organizaon, 2009).

71 WHO, Treatment of Tuberculosis: Guidelines, 4th ed.

72 L. Gresham, A. Ramlawi, J. Briski, M. Richardson, and T. Taylor, Trust across Borders: Respond-ing to 2009 H1N1 Inuenza in the Middle East,Biosecurity and Bioterrorism: Biodefense,Strategy, Pracce, and Science 7 (2009) 399404.

73 Ibid.

74 Sharon Perry, The Stanford North Korean Tuberculosis Project, in U.S.-DPRK Educaonal Ex-changes: Assessment and Future Strategy, ed. Gi-wook Shin and Karin J. Lee (Stanford: WalterH. Shorenstein Asian Pacic Research Center, Stanford University, 2011).

75 H. Seo and S. Thorson, Academic Science Engagement with North Korea,Academic PaperSeries on Korea (Korea Economic Instute) 3 (2010): 10521; P. C. Agre and V. Turekian, Ad-vancing Science, Promong Peace,Science Translaonal Medicine 2 (2010): 12.

76 D. P. Fidler, Health as Foreign Policy: Harnessing Globalizaon for Health, Health PromoonInternaonal21 (2007): 5158.

77 F. Gavin, Same as It Ever Was: Nuclear Alarmism, Proliferaon and the Cold War, Interna-onal Security34 (2009): 737.

78 Barbara Demick, Nothing to Envy: Ordinary Lives in North Korea (New York: Speigel &Grau, 2009).

79 Lewis and Carlin, Review U.S. Policy toward North Korea.



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31/31

Authors:

John Everard

Jos Luis Len-Manrquez

Yeongkwan Song

Yoon-shik Park

Michael J. Mazarr and the Study Groupon North Korean Futures

Balbina Y. Hwang

Abraham M. Denmark

Sharon Perry, Heidi Linton,Louise Gresham, and Gary Schoolnik

Duyeon Kim

On Korea began in December 2006 with the initiation of KEIs

Academic Paper Series, a year-long program that provides both

leading Korea scholars and new voices from around the world

to speak and write on current events and trends on the

Korean peninsula.

Each year, KEI commissions approximately ten papers and

distributes them individually to over 5,000 government officials,

think tank experts, and scholars around the United States andthe world. Authors are invited to the Korea Economic Institute

to discuss their research before a Washington, DC policy

audience. At the conclusion of each series, the papers are

compiled and published together as the On Korea volume.

To learn more about how to contribute to future Academic

Papers Series forums and other programs at KEI, please visit:

www.keia.org.

ark

e.

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