Drug Resistant Tuberculosis in North Korea Is a Bigger Problem Than Previously Thought

For years, the tuberculosis treatment strategy in North Korea was to give patients a short stint of antibiotics, let them get better, and then send them back into the world. This strategy worked for a while, but eventually North Korean doctors noticed the same patients kept coming back in--a sign of that antibiotic resistance had developed in the bacteria that causes the disease.

But with the country's abysmal health system and disease surveillance, doctors had no way of diagnosing or proving that multi drug-resistant tuberculosis, or MDR TB, had made its way into the population. Now they do. A study published this week in PLOS Medicine found that, of those treated for tuberculosis by Eugene Bell, an American / South Korean NGO that specializes in patients who relapse, 87 percent tested positive for MDR.

"We had anecdotal information from North Korean doctors, who were right on this one. They weren't able to diagnose drug resistance, but they could see what happens when they treated people with drugs and they came back," says K.J. Seung, a EugeneBell doctor who has spent years in the country and author of the PLOS report. "Now we have original scientific data that clearly documents drug resistance."

North Korea isn't the only country fighting a battle against MDR TB, but unlike countries such as South Africa and India, it isn't actively changing its treatment strategy.

For the last 15 years, Seung said, Pyongyang has been implementing a generally pathetic treatment strategy called DOTS--one that was originally suggested by the WHO--which has since grown severely outdated and has been abandoned in places like South Africa, a country that is perhaps the most burdened by drug-resistant tuberculosis. A DOTS treatment course consists of giving all TB patients the same, standard antibiotic until they feel better. This treatment works fine for drug susceptible patients, and might even make patients with a resistant strain feel better for a time. But it's also how you end up developing drug-resistant strains of the bacteria.

"South Africa is a middle-income country that understands there are susceptible and resistant strains of the disease. North Korea is so poor and because they had no evidence of drug resistance, no way to detect it, they gave the same, old fashioned regiment for the entire country," Seung said. "When you're infected with MDR TB, there might be a mix of half susceptible and half resistant bacteria. You'll feel better with treatment because half of the bacteria die, but the ones that are resistant grow back. You can prolong a patient's life and make them feel better with DOTS, but obviously during that time they're infecting other people with drug resistant strain."

In an op-ed in the Atlantic this week, he said a diagnosis of MDR-TB in North Korea is "basically a death sentence."

Largely forgotten in western countries, tuberculosis is still an extremely deadly disease. It killed more than 1.4 million people in 2011, mostly in the 22 "high burden" countries designated by the World Health Organization, which account for 80 percent of the world's cases.

And it's still not completely gone from the United States: It killed more than 500 people in 2009, according to the Centers for Disease Control, and a drug resistant-outbreak in New York City in the early 1990s killed 29 of the 32 people it infected.

A 2010 report by Amnesty International put the rate of multi drug-resistant tuberculosis in North Korea at 4 percent, but in the wake of the new PLOS Medicine report, that data likely vastly underestimates the true rate of MDR TB in the country.

It's impossible to say just how many people in North Korea have drug-resistant strains of TB, because the national surveillance data there is so paltry, a fact that Seung notes is "disturbing."

Like many problems in North Korea, the tuberculosis outbreak can largely be blamed on malnutrition and overwhelming poverty. According to the World Health Organization, the tuberculosis epidemic in North Korea can be attributed to the "overall deterioration in health and nutrition status of the population as well as the rundown of the public health services." North Korea's tuberculosis rate of roughly 5 percent is higher than some countries that are also experiencing an HIV epidemic--the two diseases are often linked together, because TB tends to strike those with compromised immune systems. But HIV is essentially nonexistent in North Korea, meaning general malaise is likely to blame. Approximately 15,000 people die of tuberculosis there each year.

But here's the good news: While North Korea is an extremely poor country, it does have the money to treat tuberculosis. In 2010, the Global Fund to Fight AIDS, Tuberculosis and Malaria, in concert with UNICEF and WHO, allocated $41 million to fight TB in the DPKR. Seung says that fighting MDR TB is "well within a budget of $41 million."

But that doesn't mean they will fight it: Though North Korea's government is notoriously closed to suggestions from outsiders, they have been fairly willing to work with outside organizations on the TB problem, Seung said. But the sheer numbers of TB patients there has overwhelmed the health system, and the DOTS strategy largely continues.

"There's a lot of money that's going into North Korea for TB control, but it's not addressing the problem at all," he said. "I hope this paper will help change that."

Perhaps paradoxically, North Korea's isolation, and the one-size-fits-all strategy they've taken to fighting TB actually means that public health officials have a fighting chance of beating the thing.

In countries such as South Africa, the failure of second-line antibiotics have led to totally drug-resistant (TDR) strains of tuberculosis that are virtually untreatable. In fact, scientists there described the first instances of "totally drug-resistant" TB earlier this year. For those patients, there is no cure. But because only common antibiotics have been used on North Korean TB patients, their strains of MDR TB should still be susceptible to many of the drugs we still have.

"This is not a sad study," Seung said. "Compared to South Africa, they're in a better situation. There isn't any TDR there. In poor countries like North Korea, they don't have access to the second line drugs, so they haven't yet developed resistance. We want to go in with the right drugs at the right time."