Correction to This Article
This article about hospitals in North Korea incorrectly referres to "the late evangelist Billy Graham." Graham, 89, lives near Asheville, N.C.
Giving Until It Hurts
For a decade, Stephen Linton has been battling an epidemic of tuberculosis -- and the world's most obstinate bureaucracy -- in North Korea, a country few foreigners are allowed to even see

By Stephen Glain
Sunday, March 9, 2008

STEPHEN LINTON IS BEING HUSTLED THROUGH THE DARKENING CORRIDORS of Hadan Tuberculosis Hospital in western North Korea. It took him three hours to get here from Pyongyang, the capital, which is linked tenuously to Hadan by 50 miles of deeply rutted and washed-out roads. A diminutive man with a craggy face and patrician silhouette, Linton has just finished unloading a cache of medical supplies, and now the hospital director, who wears a white lab coat and a head covering that could double for a baker's hat, wants him to observe a surgery. But they'll have to hurry: It's already late in the November day and, in a country where electricity is tightly rationed, a surgery's outcome can hinge on how much sunlight is pouring through operating room windows.

With orderlies and aides struggling to keep up, the two men canter through the hospital's drafty administrative building, with its faux-Palladian facade and faded, royal-blue window shutters, and across the dry empty fields that envelop the compound. The operating room is a two-story concrete blockhouse; to get to its main entrance, visitors must pick their way through spent oxygen tanks strewn along the pathway.

The patient is a young woman whose lower spine has been corroded by tuberculosis. She is lying on her side on the operating table, and an orderly is coating her lumbar region with disinfectant iodine. The surgeons will try to repair the damaged vertebra by grafting onto it a slice of bone taken from the patient's pelvis. There is no heat. Barring complications, the operation should take two hours, which would be plenty of time during the summer months, but could be a close call this late in the year.

Linton, 57, stops to peer through a window from the operating room's antechamber.

"I've seen doctors who tried to capture sunlight by reflecting it from a mirror," he says.

By North Korean standards, the patient is fortunate. She's been given a local anesthetic, which is rare in a country where surgeons routinely etherize patients, strap them down and try to finish the operation before they come to. The operating table is less than a year old, as are the surgeon's instruments and the handcarts on which they're arrayed. Also new are the hospital's X-ray machines, electrocardiogram, oxygen tanks and wheelchairs. All this is courtesy of Linton's Eugene Bell Foundation, a Maryland-based nongovernmental organization that has spent the past decade battling a raging tuberculosis epidemic in areas of North Korea where few foreigners have been allowed to travel.

It's not easy work. Of the 36 NGOs that began operations in North Korea as famine gutted the rural population in the mid-1990s, all but a handful have left in frustration. And Linton is particularly demanding: He insists on delivering his supplies personally, lest they be diverted to another facility or end up on the black market. When government officials balk, Linton refuses to resupply the site. So each of his two resupply visits annually is preceded by lengthy and sometimes rancorous negotiations. "Our donors feel very passionate about where their money goes," Linton says. "A lot of them are part of the Korean diaspora, and some are even from North Korea, and they know exactly what kind of facilities they want to help."

It has taken Linton years of resupply missions to build a redeemable store of trust with the North Korean government. On this visit, he has brought with him the first cycle of medicine for tuberculosis victims who have become resistant to the drugs most commonly prescribed for the disease -- a condition known as multidrug resistance, or MDR. Success hinges on Linton's direct access to the patients -- including ones at care centers near remote military bases and other sensitive areas. Without that, he'll take the MDR kits back with him to Seoul.

"What strikes me about Steve is his ability to persevere in a system that does not work well and maintain the integrity to say, 'No,'" says Charles "Jack" Pritchard, who, as a former special envoy for negotiations with North Korea and a member of the National Security Council, has known Linton for years. "He's had problems from Day One, but he's overcome."

The progeny of several generations of Christian missionaries, Linton spent most of his youth in South Korea. He speaks flawless Korean, marshaling it to shame obstructive bureaucrats in Pyongyang, charm hospital staffs in Kosong and bring assemblies of donors in Seoul to tears. He has insinuated himself into one of the world's most forbidding and totalitarian regimes with strategic gifts: tuberculosis drugs for the elites (in Pyongyang, the disease carries a social stigma that can ruin a career) and, say, rebuilt carburetors for parts-starved truck drivers.

South Korean sources suggest that tuberculosis has affected as much as 5 percent of North Korea's population of 23 million. Linton estimates the Eugene Bell Foundation has treated up to 250,000 patients, 70 percent of whom might have otherwise died. The foundation has a staff of seven full-time and three part-time employees, and it raises $2 million to $3 million annually. But for him, personally, the work has come with some costs: estrangement from his family, a divorce.

Health risks are ever-present. At each site, Linton interviews tuberculosis victims for a videotaped log that will be featured in his next presentation to potential donors. He's frequently warned by his North Korean minders, physicians who accompany him from site to site, to wear a mask, but he refuses.

"I can't raise money wearing a mask," he says.

LINTON'S FOUNDATION IS NAMED AFTER ONE OF HIS GREAT-GRANDFATHERS. A farmer's son and Presbyterian missionary from Kentucky, Eugene Bell went to Korea with his family in the 1890s as part of a post-bellum onslaught to Christianize the East. The connection has endured through generations: Eugene's son William founded what is now Hannam University in Taejon, South Korea; his son Hugh, Stephen's father, brought his wife and children over in 1954, after serving in South Korea during the war. Stephen attended schools there and obtained graduate and postgraduate degrees in Seoul and the United States, including a PhD in Korean history at Columbia University. In the early '90s, while Linton was working at Columbia, the late evangelist Billy Graham tapped him as an interpreter on two visits to North Korea.

In 1997, with North Korea nearly extinguished by famine, Linton left Columbia to help the country's ministry of public health organize international aid efforts. It was a formative experience. While in the city of Sinuiju on the North Korea-China border, Linton leased a freight car and loaded it with packages of instant meals meant for famine-relief centers. But bureaucratic snarls meant he had to wait two weeks to distribute the cargo. "I still have nightmares from watching children picking out kernels of corn from railroad ties," he says.

Linton has been battling North Korea's health crisis and its commissars ever since.

"THIS IS A NASTY BUSINESS," LINTON SAYS, grimly spooning mocha mix into his morning coffee on the first day of the fall mission. His eyes are bleary. He spent much of the night before negotiating with health ministry officials over rounds of soju, the potent Korean liquor. "They say they want to save wear and tear on the vehicles, so they need to cut our sites by a third. Fine. I'll cut theirs as well. Mary, I'll need a red marker."

Linton and his six-person delegation have settled in at the Kobangsan Guest House in Pyongyang, where they were installed by government minders after flying in from Beijing the day before. The Kobangsan, a four-story villa perched regally on the banks of a man-made lake, once accommodated visiting heads of state. The ministry of foreign affairs now runs it as a lodge for NGOs and deep-pocketed VIPs. The building affords sweeping views of Pyongyang's stark rural outskirts and boasts a bowling alley, a banquet hall, a billiards room, a karaoke lounge and a lavishly appointed VIP suite with an eight-track stereo player in the bed's headboard.

Linton's delegation breakfasts in a well-lit dining area, served by female attendants in red dresses. (When not seeing to guests -- which is often, as the Kobangsan appears to be otherwise vacant -- staff members occupy themselves by watching old films on a television in the lobby.) Linton is fatigued and agitated. The previous evening, the ministry of public health, the agency responsible for Eugene Bell's work in North Korea, had suddenly announced that a banquet honoring Linton and his delegates would begin an hour early.

"They knew what was coming," Linton says. "We were up until 1:30 a.m., negotiating. They thought if they got me liquored up I'd let things pass. But I told them I wasn't drinking because I was so concerned about the scheduling."

Most of the cancellations involve small sanatoriums in rural areas -- the very sites his donors are so keen to support. Linton suspects his hosts want to avoid those facilities because, relative to the urban care centers, their poor sanitation makes them legitimately hazardous. And the wear-and-tear issue isn't just a red herring. Spending days crisscrossing the countryside on unpaved roads takes a huge toll on the delegation's fleet of SUVs -- vehicles that, between Linton's visits, the ministry is allowed to use for its own purposes. In resource-starved North Korea, even government officials must barter to replace broken fan belts and transmissions. The last thing the bureaucrats want is to risk losing a precious automobile.

Whatever the reason for the recalcitrance, Linton decides to meet his hosts head-on by matching each canceled visit with a cancellation of his own -- mostly at the expense of hospitals the ministry appears to favor. This choice comes with real consequences for both sides: Some patients will die without the fresh supply of drugs. And some of Linton's donors will be angry that the care unit or hospital wings they gave money to support ended up being passed over.

Linton has requested an afternoon meeting with health ministry officials in a bid to get back at least some of the canceled visits.

"This is a nasty business," he repeats. "But we'll get through it."

THE MEETING CONVENES PROMPTLY AT 2 p.m. in the Kobangsan's imposing conference room. Surveying the proceedings from just below the 16-foot ceiling are five-foot-tall portraits of North Korea's late founder, Kim Il Sung, and his son and current strongman, Kim Jong Il. On another wall is a vast mural of a snarling tiger set against a range of snow-swept mountains.

Linton, in coat and tie, unveils his schedule revisions. He produces a Eugene Bell "memento book" -- a binder with profiles of each center and the donor or donor group that supports it -- and slashes through five separate pages with a pink highlighter. (Mary Lyso, his able assistant, was unable to find the requested red marker, but the point is made.) He asks that the directors of care centers that the health ministry struck from the original schedule be gathered in Pyongyang so they can obtain their MDR kits from him.

Linton's three Korean counterparts are seated beside him in midnight-blue tukinyubus -- closed-collared tunics and matching trousers that resemble Mao suits. They take notes feverishly, and the meeting concludes with awkward handshakes and forced smiles. Linton later explains that the North Koreans agreed to restore only one care unit to the list. They said they'd consider his request about the MDR kits but couldn't make a decision yet. Thin gruel, but Linton claims a tactical victory. "Fewer visits means we'll be able to spend more time with the care centers and their staff," he says. And things may still change. "It's only a matter of time before the ministry starts getting angry calls from physicians demanding to know what happened to their shipments. Hopefully that will persuade the ministry that we must have access to those sites next year."

After dinner that evening, Linton brings the Bell delegates to his room to show them the MDR formulas. Drug resistance among tuberculosis patients is a problem anywhere treatment regimens are either improperly administered or simply not completed. Often a patient will ask to be discharged, thinking himself cured, only to return home and spread the disease to his family. Even in Pyongyang, where tuberculosis is not nearly the prolific killer it is in the countryside, the disease is frequently misdiagnosed as a persistent cold.

When patients show obvious symptoms but do not respond to medicine taken orally, doctors inject isoniazid and ethambutol, part of a common four-drug tuberculosis regimen, directly into their lungs. It is a painful process: In North Korea, the needles required are often so dulled by repeated use that they can only be inserted with pliers. And the more of the regimen the patient receives, the stronger his or her resistance becomes.

The MDR kits are stacked in a corner of Linton's room, which is cluttered with everything from stethoscopes to auto parts. There are 20 kits in all, sealed in boxes about a foot square, each costing about $1,000 and bearing the name of the patient whom, based on sputum samples Linton collected during his previous visit, it was designed to treat. If distributed, the kits will supply patients with the first third of an 18-month treatment.

Snaking out from the Kobangsan grounds the next morning, the Eugene Bell convoy -- two Mitsubishi Pajeros, a Kia sedan and a cargo truck -- prompts curious looks from ordinary North Koreans and salutes from soldiers. First stop is a warehouse district on the outskirts of Pyongyang, where international aid agencies store their goods. The road there leads past a coal mine district, where laborers draped in mantles of black dust squat not far from the roadside, scooping rice out of a bucket with cupped fingers. Nearer to the city, farmhouses give way to residential complexes -- warrens for the proletariat, many with ground-floor windows protected by security bars.

The warehouse district is located near a bus terminal and surrounded by housing blocks with corrugated steel roofs. Clustered together are Quonset huts identified by the logos of the NGOs that use them. Linton is encouraged to see Eugene Bell goods stacked neatly with the foundation's logo facing outward. He takes inventory and then distributes gifts of spare auto parts and a bicycle to the warehouse staff.

The Eugene Bell logo, a schematic image of two people in a rowboat, is a reference to a Korean folk tale about two brothers who feud with each other over an ingot of gold. When the dispute threatens to destroy their family, the siblings row out to sea and toss the gold overboard. It is a metaphor for Korea's geopolitical divide, but it could also stand for the Linton family's own breach.

In the late 1990s, as Linton was making the transition from academia to full-time aid work, two of his siblings and a close friend quit Eugene Bell in a dispute over donor solicitations. Linton was left with $10,000 and a Rolodex of donors. For a while he lived off his savings. Then his wife of 20 years left him for someone else. "All of this took place on a stage," he says, "where everyone is watching in horror and fascination and you can't just disappear."

Today, Linton lives in a Victorian-era house in the Howard County town of Clarksville spending most of his free time renovating a guesthouse on the small estate. He has since remarried.

EUGENE BELL'S FALL RESUPPLY CIRCUIT covers hospitals and care centers from the west-central part of the country north to the border with China. The group averages two resupply visits a day, and much of the time is spent on the road. The convoy passes collectives of farmers busy wrapping cornstalks into enormous hourglass-shaped bundles and storing them for fuel, and army units gathering the remains of the cabbage crop.

The roads are lined with the ligaments of a sclerotic state: laborers shouldering homemade shovels and pickaxes, youth-brigade members, soldiers, students, oxen-drawn carts, swarms of bicyclists. Vehicular traffic consists of military convoys, the occasional passenger car smuggled in from China and a contraption known as a moktan cha, or "charcoal truck," which is powered by cornstalks converted into carbon monoxide by a retrofitted burner. A similar technology was employed by taxis in postwar Japan, according to Linton, who is something of a gearhead.

Despite its poverty, the North Korean countryside displays a tidy bucolic tableau: rows of squat farmhouses with whitewashed plaster walls trimmed in apricot or blue, and dried cornhusks suspended above the entryway. Children attempt to ice-skate across frozen rice paddies. Thrust among these delicate vignettes are imposing billboards and monuments, usually superimposed with portraits of Kim Il Sung, imploring citizens to struggle, to resist, to endure, to work hard, to observe clean work habits, to smile.

The site visits assume a familiar rhythm. Fresh supplies are stacked neatly in front of the administration offices with the Eugene Bell logo clearly visible. Unboxed goods, such as wheelbarrows and tractors, are lined up nearby. Aside from international inspections of Pyongyang's nuclear facilities, the Eugene Bell resupply tour could be North Korea's most thoroughly documented event. Once the Bell delegation arrives, Linton performs what he calls a "hello-how-are-you" shot, a brief videotaped exchange with the facility's director and a quick explanation of what supplies are being delivered and who donated them. Staff members are summoned to hold banners with the donor's name in front of the shipment, or attach stickers with the proper logos onto each box. When the cargo is funded by several donors, teams of staff members are rotated before the cameras with the appropriate banners. Every delivered item is accounted for on a manifest that is signed on camera by the site director. It is an exhausting archive of data and images that over the next several months will be edited and collated to create both a report for each donor and a memento book that Linton will present to the hospital or sanatorium on his next visit, complete with extra photos for the staff.

On the fourth day of the tour, Linton and his delegates stop at the Kosong People's Hospital, a whitewashed building with rounded corners and neatly painted gray windowpanes. A team of physicians in threadbare, stain-spattered scrubs escorts them into the head office and sits down at a long table that extends perpendicularly from the director's desk, which is set parallel to the wall opposite the doorway. Above the desk are framed photos of the elder and younger Kims. On the desktop are two phones from the Sputnik-era East Bloc and a day-per-page datebook made of coarse recycled paper. (During the two-week tour, the delegates are received by 12 directors, and each office is identical to the other. The telephones rarely ring, and the daybooks are blank.)

The Bell delegates are treated to helpings of sweet potatoes and whole chestnuts, peanuts in their shells, apples and tea. Like the rest of the facility, the office is unheated, so coats stay on. Linton sits closest to the director as, for about an hour, the two men discuss the hospital's future needs. The meeting could be wrapped up in less time, but Linton doesn't want to risk appearing rude. By the end of the discussion, two small pyramids of potato peels and chestnut skins have accumulated on the desk before him.

The director then escorts the delegation on a tour of the hospital and its equipment, much of which predates the Cuban missile crisis. Like most hospitals and care centers in North Korea, the facility employs a direct-fluoroscopy machine, an X-ray device that irradiates the patient from behind while the doctor examines an image projected on a fluoroscopic plate of glass between them. "The negative is the doctor's retina," says Linton, who frequently admonishes physicians for submitting themselves to the machines' potentially fatal doses of radiation. Most physicians in North Korea use them regularly, and suffer the consequences. The radiologist at Kosong, for example, has receding gums and low hemoglobin, common signs of radiation sickness. Three of his colleagues have died over the years -- one from radiation overdose, another from cancer and a third from tuberculosis.

Like their counterparts throughout a country isolated by international sanctions, the physicians at Kosong have become expert scavengers and foragers. They fashion their own surgical instruments with the help of local blacksmiths. The hospital's

tuberculosis wards -- long, narrow dormitories warmed by wood stoves -- share space with thickets of cotton plants that provide the fibers needed for gauze or bandages. A common Eugene Bell donor item is plastic sheeting for greenhouses to nurture fresh vegetables and other produce for the patients' nutritional needs. Physicians even harvest one another: Earlier, the director and three of his colleagues had lowered their trousers to reveal fresh scars on their inner thighs where patches of flesh had been sliced away to be used in skin grafts.

One thing North Korea's medical community cannot jury-rig, however, are medical textbooks. When Linton opens a carton of South Korean books, Kosong staff members set upon them hungrily. Forty minutes later, when orderlies are asked to gather the books for registration with the health ministry, a nurse holds hers tight to her chest, clearly loath to relinquish it.

Before saying goodbye, Linton inspects the hospital's emergency vehicles, bantering with the maintenance crew as he distributes fresh shock absorbers and air filters. In mock reproach, he scolds a mechanic for having dirty fingernails, then rewards him with a wristwatch for keeping detailed service records. The damaged auto parts have already been removed and sorted on a burlap sack, like freshly removed organs.

Linton will take these back with him to Seoul. "Otherwise," he says, "they'll end up in some black-market stall."

THE IMAGES THAT MELT LINTON'S DONORS' HEARTS is footage of him interviewing tuberculosis patients in their wards. With a practiced hand, he pins a microphone on the patient's clothing -- more often than not Eugene Bell-issued pajamas -- and begins a short interview. At a sanatorium in Dongdaewon on the eighth day of the tour, Linton meets a 27-year-old woman who contracted tuberculosis after her discharge from the military. She was diagnosed in a city hospital and sent to the care unit after she failed to respond to treatment, which suggests MDR.

"I took my medicine just like everyone else, but I was the only one who didn't get well," she tells Linton almost apologetically, her eyes darting nervously from one corner of the room to the other.

Linton addresses her in his light South Korean drawl. "You're my model today," he says soothingly, and she manages a weak smile.

The quiet is perforated by the sound of patients in the corridors hawking up expectorant for sputum samples. The woman has already given hers, which is stored along with the others in a cooler that Linton will take with him to South Korea for testing. With luck, he'll bring a treatment kit to her in the spring.

THE TWO-WEEK TOUR ENDS WITH A VISIT TO A TUBERCULOSIS FACILITY NEAR SADONG, a district in a distant part of the Pyongyang municipality. Like other care centers on the capital's periphery, this one is near an army base and a cemetery. Linton and his team are welcomed warmly by the director, a tall man with facial fluoroscopy burns that give him a perpetual blush.

While inspecting the wards, Linton enters a cell crowded with five men of varying ages. They have three cots among them and give in to fits of deep, gravelly coughs. Most wear ragged army fatigues. The sun is setting, and the atmosphere is sepulchral. Linton manages to get a few wan laughs but shakes his head as he steps back into the receding daylight.

"It's the end of the line in there," he says. "I doubt if any of 'em will make it, save one or two." Nevertheless, the men's sputum samples are collected and deposited with the others.

It is getting late. The delegates will have to hurry back to Pyongyang to beat curfew. They hastily say goodbye to the staff and board their SUVs.

On the road back, no lamps illuminate the highway, and many of the vehicles on the road have no working headlights. The Bell convoy sweeps past the relentless procession of workers, students and soldiers, going from daylight into night, stopping only for the occasional military checkpoint.

That evening, from a room now eerily vacant of MDR kits and spare car parts, Linton will begin preparations for the spring tour.

Stephen Glain is a contributing editor for Newsweek International based in Washington. He can be reached at s.glain@verizon.net.

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