North Korea has high rates of multidrug resistant tuberculosis — and the situation could get worse if the Global Fund ceases grants to address the country’s TB and malaria needs. (iStockphoto/Getty Images)

A Bloomberg News report this week warned of the threat of North Korea’s “other weapon” — tuberculosis. In February, the Global Fund to Fight AIDS, Tuberculosis, and Malaria announced that it would suspend grants to combat tuberculosis and malaria in North Korea by June 30.

Global Fund officials stress that they hope to resume funding to the country in the future, and North Korean officials have implored the Global Fund to maintain its funding on humanitarian grounds.

Since 2002, this partnership among governments, the private sector and civil society groups has awarded more than $33 billion in grants to treat HIV/AIDS, tuberculosis and malaria to save more than 22 million lives in more than 100 countries. From 2010 to 2017, the Global Fund provided more than $69 million for tuberculosis and nearly $34 million for malaria treatment in North Korea. So what’s going on North Korea now?

1. Why did the Global Fund suspend grants in North Korea?

That’s a good question — and there isn’t yet a clear answer. The announcement on the Global Fund’s website refers to the organization’s “strict zero-cash-advance policy” and refers to the need to maintain detailed records on how and where health and medical supplies were delivered, but there have been no public allegations about any particular scandals or problems.

Global Fund officials say that North Korea’s “unique operating environment” meant they couldn’t guarantee compliance with their standards — despite the fact that the Fund rated North Korea as “exceeding expectations” in a recent grant assessment.

By contrast, when the Global Fund suspended its HIV/AIDS grants to Uganda in 2005, it did so after publicly announcing that audits revealed high levels of corruption and theft.

Some health organizations working in North Korea described the decision as unexpected, especially in light of the organization’s commitment last year to continue working in North Korea despite the government’s nuclear tests.

The North Korean government has publicly worried about the effects on tuberculosis and malaria infection rates. North Korean officials also stated that the Global Fund made its decision without consulting either UNICEF or the World Health Organization.

2. What is the scope of the Global Funds operations in North Korea?

Compared with those in other countries, North Korea’s Global Fund programs are relatively small. Over the past eight years, the organization supported the treatment of more than 194,000 cases of TB and distributed almost 2.3 million insecticide-treated bed nets.

But the Global Fund is one of — if not the — only funders of malaria and TB treatment in North Korea. Losing this financial support will have a serious effect on the country’s efforts to control both diseases.

3. Are TB and malaria big problems for North Korea?

In a word, yes — the TB situation is particularly alarming. Getting exact health figures for North Korea is a challenge, but WHO includes North Korea on its list of 30 high TB burden countries. The country has one of the highest rates of TB infection outside of sub-Saharan Africa. In 2014, WHO estimated that 5,000 North Koreans died of tuberculosis, which meant the TB death rate was more than five times higher than in neighboring South Korea.

Making the situation all the more challenging, North Korea has increasing rates of multidrug resistant TB (MDR-TB). When access to treatment is limited or interrupted, the likelihood of patients developing MDR-TB increases. MDR-TB is even harder and more expensive to treat, which makes the problem even worse. And this is exactly the situation North Korea will face when the Global Fund grants end.

Most countries with extensive TB spread also have high rates of HIV prevalence. North Korea does not. Instead, North Korea’s TB epidemic is fueled by chronic malnutrition and lack of treatment access.

North Korea had effectively wiped out malaria in the 1970s, but the disease resurged in the late 1990s in the face of the country’s economic collapse. The number of cases peaked in 2013 at nearly 24,000 but dropped to approximately 5,000 in 2016. Despite the decline, WHO estimates nearly 40 percent of the North Korean population lives in at-risk areas for malaria infection.

The threat from malaria and TB in North Korea is a concern to neighboring countries, as mosquitoes and bacilli pay little attention to national borders. Chinese officials worry about the spillover effect of North Korea’s TB problems — both as a disease threat in China and as a potential destabilizing force in the region.

4. What will happen when the Global Fund grants end?

North Korea has decreased its rates of both TB and malaria since 2010, but that success depends on continued access to the drugs, personnel and resources necessary to keep these programs going. Suspending the grants risks creating medical and humanitarian crises.

It also signals a suspension of health diplomacy efforts. The Global Fund programs allowed other countries to positively engage with the country. The United States and North Korea have few direct ties, but the Global Fund offered a route to collaborate on tuberculosis control.

5. Is the Global Funds decision political?

Maybe — it’s hard to separate any issue involving North Korea from broader international relations concerns. The North Korean government slammed the Fund’s decision for coinciding with the further deterioration of relations with the United States, suggesting that the Fund was trying to advance U.S. diplomatic interests.

More broadly, the sanctions imposed against North Korea by the United Nations and various national governments present challenges for any health-related programs in North Korea. When South Korea strengthened sanctions against the North in March 2016, it did not create any exceptions for humanitarian concerns. As a result, nongovernmental organizations trying to import TB drugs couldn’t get the export licenses they needed.

Aid organizations working in North Korea have reported significant delays in getting drugs, building supplies and medical equipment as sanctions have strengthened. This doesn’t mean that sanctions are targeting the ill in North Korea; rather, it’s a reflection of the tensions that can emerge between diplomatic and humanitarian interests.

Jeremy Youde studies global health and international relations at the Australian National University. Follow him at @jeremyyoude.