This past week, the world watched in amazement as the leaders of the two Koreas met, shook hands and stepped over the dividing line between the two countries. People all over the world sighed with relief at the easing of tensions.
North Korea experts appeared on television, arguing breathlessly about the meaning of every glance and phrase. And a small community of public health experts gazed quizzically at the screen, thinking, “wait, remind me again why the Global Fund just pulled out of North Korea?”
In a decision that garnered little media coverage, on February 21, the Global Fund to Fight AIDS, TB and Malaria (known more generally Global Fund) announced that it was suspending its grants in North Korea, after eight years of working in the country.
Global Fund spokespeople explained only that “…the unique operating environment in the DPRK prevents us from being able to provide our Board with the required level of assurance and risk management around the deployment of resources.”
There are two in-country Global Fund programs: a smaller one to control malaria in the southernmost provinces bordering South Korea, and a larger one to control tuberculosis, which is a major problem nationally. Both programs are implemented by UNICEF and the World Health Organization (WHO).
For those with an understanding of the tuberculosis epidemic in North Korea, the sudden announcement came as an unwelcome shock. North Korea has one of the highest TB rates in the world. While this epidemic is largely invisible to journalists and tourists, as a medical doctor that regularly visits North Korea as part of the Eugene Bell Foundation, a U.S. and South Korean NGO, I can attest that TB is a public health crisis that affects ordinary North Koreans.
TB is common in all provinces, in rural and urban areas, and strikes down young people at every level of society. We also know that drug-resistant strains of TB have been increasing for some time, and that the North Korean health system, like that of other developing countries, is ill-equipped to deal with such a complex disease.
For those of you who have never seen first-hand someone suffering from TB, I recommend that you watch “Out of Breath”, a new documentary on drug-resistant TB in North Korea.
North Korea has one of the highest TB rates in the world
Over the past eight years, the Global Fund has disbursed more than USD$100 million for North Korea, of which nearly USD$70 million was spent on TB control, including TB drugs, TB diagnostic equipment, and other commodities.
This is a relatively small amount of money relative to Global Fund grants in other countries, yet was huge for North Korea, which receives very little humanitarian aid of any kind. Bilateral government-to-government aid is practically non-existent, and most international organizations and even NGOs refuse to work there due to the difficulty of working with the DPRK government.
Global Fund, however, is an important exception. This is the largest external investment in the health of the North Korean people in history, and by all accounts extremely successful. Global Fund has extensive experience of working in countries with unstable or problematic governments and has successfully developed financial systems to work in them.
No money goes to the North Korean government; UNICEF and WHO have been responsible for procuring drugs, equipment and commodities outside the country and then ensuring they were distributed correctly inside the country. Thus far, these systems have worked impeccably. There has been no evidence of fraud, corruption, or misuse of funds.
Despite the relatively small size of the Global Fund TB grant, especially compared to the magnitude of the TB crisis, its impact cannot be overstated. Over the past eight years, I have seen major improvements in the North Korea TB control program, including importation of quality-assured TB drugs and introduction of new DNA-based diagnostic technology.
All of these gains are threatened by the sudden and mysterious decision to suspend operations by June 30. A staggering 120,000 patients are treated with Global Fund drugs every year. That quantity of drugs cannot be procured in a few months, raising the possibility of national stock outs. The suspension of Global Fund support, and the absence of any coherent exit strategy, is likely to lead to creation of more drug-resistant strains, as doctors ration pills and patient take incomplete regimens.
For members of the global health community, the other disturbing aspect of the Global Fund’s decision is the lack of transparency surrounding it. While the Global Fund has been forced to exit countries in the past, usually in response to financial misfeasance, no such incident has been reported in North Korea. Nevertheless, the Global Fund’s public statements about the decision have consistently been couched in a way as to suggest that such an incident did take place.
In the past, the decision to suspend Global Fund grants has been preceded by formal audits by the Office of the Inspector General, multiple newspaper and magazine articles, and extensive discussion by the Board of the Global Fund.
With North Korea, the lack of Board discussion is particularly surprising in light of the potential effects on TB control in a high-burden country and the lack of any clear precipitating incident. The lack of transparency not only sets a bad precedent, but also leads Global Fund observers to naturally leap to the conclusion that the decision was influenced by political considerations.
Global Fund has extensive experience of working in countries with unstable or problematic governments
Finally, everyone should be concerned about the moral aspects of this decision. As someone who has worked in North Korea for years and has no illusions about the difficulty of working in the country, I certainly can appreciate that Global Fund has experienced frustration with the government’s chronic lack of transparency. But this is not sufficient justification to suspend its grants. If global health organizations only chose to work to countries with “good governance,” I probably wouldn’t be traveling to any of the countries where I work.
Because North Koreans are largely cut off from external humanitarian aid, they desperately need support from the Global Fund, which was designed to operate in the most difficult environments, free of political pressure that can block governments and NGOs. When the Board of the Global Fund meets on May 9, I hope they will reverse the decision to pull out of North Korea, not because the political winds have changed, but because they believe, as I do, that all people deserve health care for treatable illnesses, no matter the government under which they live.
As Stephen Linton, head of the Eugene Bell Foundation, says, “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.”
Our culture is dominated by 24-hour news coverage and endless political analysis. We are transfixed by cheerleaders and summits, and speculation about who is going to win the Nobel Peace Prize. But we are letting the Global Fund’s sudden and mysterious decision—which will affect millions of North Korean lives—pass without explanation or discussion.
In our obsession with all things North Korea, let’s not forget the people who actually live there.
Edited by Oliver Hotham
Featured Image: UNICEF