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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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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.
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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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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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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
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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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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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19 WHO, Muldrug and Extensively Drug-Resistant TB (M/XDR-TB): 2010 Global Report onSurveillance and Response, report no. WHO/HTM/TB/2010.3 (Geneva: World Health Or-ganizaon, 2010); N. R. Gandhi et al., Muldrug-Resistant and Extensively Drug-ResistantTuberculosis: A Threat to Global Control of Tuberculosis, Lancet375 (2010): 183043.
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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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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
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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).
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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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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.
65 Gandhi et al., Muldrug-Resistant and Extensively Drug-Resistant Tuberculosis.
66 WHO, Muldrug and Extensively Drug-Resistant TB (M/XDR-TB).
67 Gandhi et al., Muldrug-Resistant and Extensively Drug-Resistant Tuberculosis.
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.
Perry, Linton, Gresham, and Schoolnik: Engaging North Korea
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30 2012 Volume 5 n ON KOREA
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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
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