
One of the few foreign aid groups operating in North Korea and the only privately funded NGO treating tuberculosis (TB) has identified a growing challenge in reducing TB in the North: the increasing prevalence of multidrug resistant tuberculosis (MDR-TB) that is more difficult and more expensive to treat than regular TB.

“Multidrug resistant TB requires more precision, the medicine costs alone are 150 times as high, there’s a lot less margin for error,” Stephen Linton tells The Diplomat in an interview.

Linton chairs The Eugene Bell Foundation, the Seoul-based organization that is dedicated to treating TB patients in North Korea.

The foundation began working in North Korea during the 1990s after being invited by the government to provide food aid to people impacted by the famine that ravaged the country. After two years of providing food aid, the North Korean government asked the organization to switch to TB treatment as the malnutrition the famine caused led to a spike in the number of North Koreans infected with TB. The foundation agreed.

According to the World Health Organization’s (WHO) 2012 Global Tuberculosis Report, there are 345 TB infections per 100,000 people in North Korea, one of the highest in the world outside of sub-Saharan Africa.

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Precise statistics on multidrug resistant TB in the North are not available.

In a March press release, the WHO and the Global Fund to Fight AIDS, Tuberculosis, and Malaria called for increased funding for the treatment of multidrug resistant TB, calling it the area of TB treatment that needed funding most urgently.

The North Korean state’s capacity to treat TB is lacking, particularly when it comes to treating multidrug resistant TB. The Global Fund therefore provides funding and WHO-approved medication to North Korea’s National TB Control Program.


“The National TB Control Program has only started to implement the MDR-TB program on its own since 2012, therefore their capacity is not yet at the level where they could treat every single person with MDR-TB,” said Marcela Rojo of the Global Fund.

To be cured, TB patients require a course of four different antibiotics for a minimum of six months. If treatment is interrupted or not completed, the exposure to the drugs can cause the TB strand to mutate and become drug resistant. Eugene Bell estimates that 15,000 people in North Korea fail to complete their treatment for regular TB each year.

Eugene Bell’s medical director and physician, Kwonjune Seung, argues that the primary reason multidrug resistant TB has become more prevalent in North Korea is because the Global Fund doesn’t provide enough treatment for MDR-TB. Marcela Rojo of the Global Fund, however, denied such a connection in a written statement to The Diplomat.

Although Article 56 of North Korea’s Constitution stipulates free medical care for all citizens, the North Korean government has been unable to afford the system since the economic downturn in the 1990s. As a result, access to healthcare is no longer universal and many illnesses go untreated if the patient is unable to provide money or gifts to doctors, according to a 2010 report by Amnesty International, which was based on interviews with more than 40 North Korean defectors.

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South Korean groups who hope to fill the gap in treatment have to have their activities in North Korea approved by South Korea’s Ministry of Unification. This often leaves them hostage to the ebb and flow of inter-Korean relations.

For example, the 2010 sinking of the Cheonan warship and shelling of Yeonpyeong Island brought inter-Korean relations to their lowest point in years. As a result, the Lee Myung-bak government prohibited South Korean aid groups from continuing their work in North Korea. Eugene Bell’s non-South Korean staff members were able to continue their semi-annual trips to the North, because they are foreign nationals, though the shipments of medicine still required government approval because they are made from South to North Korea.

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Its most recent shipment of medicine to the country in the spring of this year –intended to treat the foundation’s 600 patients – was approved by the Seoul government, making it the only private group to receive such permission.

Nonetheless, Linton, Eugene Bell’s chairman, notes that the Ministry had delayed approval until the last possible day. This forced the group to purchase US$606,500 of TB medicine without knowing whether it would be granted permission to ship it to the North.

If it hadn’t received permission, Eugene Bell’s patients’ treatment would have been disrupted, possibly causing many to develop the multi-drug resistant strain of TB.


While declining to comment on the specifics of the Eugene Bell case, Oh Dae-seok, Director of Humanitarian Assistance Division at South Korea’s Ministry of Unification, told The Diplomat by email that, “The government respects the good intentions of humanitarian aid. Permission depends on who will receive the aid, the effectiveness, urgency and the type and scale of items. These factors are all comprehensively considered,”

According to Linton, the basis of his organization’s ability to work in North Korea is trust, built over years of contact and an indefinite commitment to its work the country. The Foundation is also careful to maintain its apolitical identity as an organization exclusively devoted to public health.

“We have to avoid anything that they consider a threat to their society,” Linton says. “We have no interest in doing anything there other than what we’re invited to do. We’ve followed through with our promises, even when the politics were bad. And they have been very bad at times.”

Not surprisingly, many have criticized Eugene Bell for cooperating with the repressive North Korean state.

However, the Foundation argues that there are North Koreans who are suffering from TB and they deserve assistance irrespective of the behavior of their government. After all, the Foundation notes, the TB patients have no say in their government, and it would be inhumane to punish them for something they have no control over.

“When you care about a system, or an idea, more than the people who actually live in that system, that’s when things get really brutal,” Linton explains.

Steven Borowiec is a South Korea-based writer. His work has appeared in The Guardian, The Toronto Star and Asia Sentinel, among other publications.