Choong helping to train clinical lab doctors at the National Tuberculosis Reference Lab
Contributed by: Professor Don Clark, Trinity University, San Antonio, June 2010
In late March and early April 2010 I had the privilege of accompanying Director Heidi Linton and a delegation of Christian Friends of Korea (CFK) on a “confirming trip” to North Korea, traveling in and around Pyongyang and out into the provinces of North and South Hwanghae.
Until recently I had no idea what a “National TB Reference Laboratory” is or how serious the lack of such a lab is in the DPRK when it comes to finding and treating Multiple Drug Resistant (MDR) cases of TB. Last winter’s edition of the CFK newsletter presented the importance of this project for the people of Korea and for CFK. In traveling with CFK and visiting lab in March, I could see why the project was so essential. MDR tuberculosis is a serious problem in North Korea requiring complicated and expensive treatment that can’t start until patients are properly diagnosed. This diagnosis cannot be made in North Korea, nor can an individualized patient treatment plan be designed without a functioning National TB Reference Laboratory. Lives that could be saved by earlier diagnosis are being lost.
In our suffering world there are many things that should not be. In the 21st century, people with MDR tuberculosis should not be condemned to miserable illnesses and deaths for lack of a lab to provide timely diagnoses. This is why I believe in the National Lab project and why I am so thankful that CFK, working with world experts from Stanford, the Bay Area TB Consortium, and the DPRK Ministry of Public Health, have managed to build and equip a National TB Reference Laboratory for the DPRK in just over a year. I am glad to contribute towards the final needed item: the special electrical cable needed to bring continuous power from the power supply station across the Potong River, to the facility itself.
I support CFK because I understand how important relationships are in Korea and why after fifteen years CFK is known and trusted by the North Korean authorities. This track record of experience, promise-keeping, genuine Christian concern, and “Confucian sincerity” matters in North Korea, and it has created striking possibilities for extensive and important engagement such as through the National Lab project.
In March and April as I traveled with our CFK group through rarely-seen areas of the DPRK, witnessing the situation with agriculture, small-scale marketing, electric power, and transportation, I was struck by how much North Korea needs basic infrastructure. Though I thought I detected signs of better agriculture and potential food supply for the current year, I saw little improvement in electric power, safe water supply, fuel, or public transportation, even in Pyongyang. In other words, North Korea is always just barely making it, mobilizing the fierce loyalty of the people through relentless slogans, references to external threats, and visions of a better future to which there seems to be no clear path.
Having lived in the south off and on since the 1950s in places that used to look a lot like North Korea does today, I know what it took to bring South Korea out of poverty, intermittent electricity, scarce fuel, rampant diseases, and the grossest injustices. North Korea has tremendous human potential. The people are well educated, disciplined, know how to work hard and sacrifice, and are willing to be mobilized for higher purposes. They deserve better than they get, and my hope and prayer would be that somehow, in the next decade or two, a way can be found for them to move from the present to a brighter future.
CFK has always been a leading humanitarian organization in support of the people of the DPRK. In tuberculosis work it found a niche, and in the creation of the National TB Reference Laboratory it played a unique and leading role. In some ways we have to regard North Korea—for example in food sufficiency—as an ongoing “emergency” requiring continuing shipments of food and medicine. CFK is also branching out into hepatitis treatment, meeting another medical need. But I think the long term for CFK also lies in infrastructural investments—things like the largest type of vinyl greenhouses, clean water, technical training, and installations like the National Lab.
On our trip I was struck not only by the intelligence and dedication of the people we met and by the strong potential for the North Koreans to build their own better life, but also by the physical beauty of the countryside—the increasing number of trees, the lakes and streams, and by the setting of the city of Pyongyang on the majestic Taedong River. My parents used to tell me about visiting “Peony Point” for Pyeng Yang Foreign School picnics, looking out at the river from the topmost pavilion, called Ulmildae. One morning in April, a few of us went up to Ulmildae on “Peony Point” (Moranbong, in Korean) on a brilliant spring day when the cherry blossoms were just starting to show. The city shimmered in the distance—the stadiums where they have the Mass Games, the apartments that often don’t have electricity for elevators, the great monuments. All of it was new—not there when my family called Pyongyang home. My mind was full of tumbled thoughts but even so, the beauty of the place took my breath away. I realized that I was seeing something of an illusion; but still I harbor faith that in God’s own time the illusion can give way to reality.
As I reflect on our time, I’m once again amazed at how great our God is to provide for all our needs and beyond our expectations. From all of us, thank you for your prayers and support! Miracle after miracle occurred. Although much was accomplished by hands, more importantly, relationships grew and hearts were touched.
We arrive in Pyongyang on Tuesday evening and begin work on Wednesday. Before leaving the warehouse in Pyongyang where we have retrieved our supplies for the work ahead, we learn that over 2000’ of poly water pipe along with a few other items shipped from the US cannot be found. Perhaps the rolls of pipe are still in customs or have been delivered to the work sites? Only time will tell.
Thursday we divide and travel to job sites where well drilling begins at Hwangju TB Rest Home along with work to insulate the greenhouse. Meanwhile, at Unpa TB Rest Home (an hour’s drive from Hwangju) unearthing the Unpa spring begins for the gravity system we hope to install here. There are few workers to dig the 1200’ long pipe trench there. No poly pipe is found at either site. We return to the hotel that night to learn that Pyongyang will essentially be shut down Friday through Sunday due to the national holiday celebrations for the 65th anniversary of the founding of the Workers Party of Korea (WPK). We’re told we can’t travel out of the city during that time. Heidi and the Ministry of Public Health (MoPH) team scramble to find the US pipes that were supposedly shipped, or an in country alternative. The MoPH team understands our resource and time dilemma. The thought hits us that we’ll likely not be able to finish. We’re not happy about it but all we can do is pray and do what we can.
To our surprise on Friday, MoPH gives us permission to travel to Hwangju only, but we must return early to Pyongyang. Well drilling continues there but progress is slow. The Water4 team decides before we leave that the well location will be adequate, so trenching for pipes can be started by local volunteers over the weekend. We’ll return Monday.
Saturday we can’t leave the city but are allowed to work at the National TB Reference Lab for a few hours. That turned out to be an important visit, finding and fixing a few problems and discovering one that required parts from the US that the next team could bring a few days later. We learn that the pipe from the US never shipped due to a supplier error, however the MoPH staff find similar pipe through a local source that will work with our US pipe fittings. Praise God!
Saturday night and Sunday we’re given the rare privilege of witnessing the truly remarkable WPK anniversary celebrations, including the impressive military parade, all the while we’re thinking about the tasks ahead. There will only be 3 days to complete the work; it seems an impossible task.
We discover on Monday that work has continued slowly at Unpa. The workers have completed less than 1/2 of the trenching for the 1200’ pipeline to an insufficient depth to prevent freezing. It’s not for lack of effort, however; the terrain is rocky and workers are few. We push ahead with what we can do. Meanwhile at Hwangju, a decision by the director is made to move the solar panel frame (already installed and concreted in) closer to the facility for fear of theft or vandalism, and now 100’ further from the pump. Pipe trenches have only been started. The good news is that the greenhouse team has nearly completed insulating the greenhouse.
It’s now Tuesday with only two working days left. We’re discussing compromised plans at both sites as we travel to begin work. The team nearing Unpa rest home passes a regiment of army soldiers carrying picks and shovels. To our surprise, minutes later they come marching up the single lane dirt road to the rest home. Everyone is excited. By the end of a long day the 1200’ trench is done, pipe is laid, water tank and most outlets installed, and final connections are made. The water begins to charge the 1200’ of distribution lines and begins to fill the tank from the spring. We hope (estimate) that the output of the spring will bring the tank to about 2/3 full by the time we expect to return at mid-day tomorrow. Meanwhile at Hwangju the greenhouse classroom training begins while the well drilling stops. The 12 foot deep well through stony terrain yields nearly 3 gal/min which should be adequate for solar pumping to provide over 1000 gallons/day. Progress on trenches at Hwangju is slow, but steady. The solar panel frame is moved and reinstalled and electrical work begins.
Wednesday is our last work day at both sites. Arriving at Hwangju we find more workers with shovels already making good progress. Before lunch, the pump is lowered into the well and water begins to flow as we test the solar system. The greenhouse crew successfully completes training in the afternoon. Meanwhile, on the way to Unpa, our MoPH colleague receives a phone call on his cell phone from the director of Unpa who tells him that the 2200 gallon tank was filled to overflowing at 1AM, and the local residents are “mad with joy” at the volume and pressure of the water in their new system. Upon arrival at Unpa, the water team is greeted by excited rest home attendants and local residents. The Unpa team completes the work, enjoys a quick celebratory lunch hosted by Unpa Rest Home, and heads for Sariwon TB Rest Home to complete an assessment for a possible future water project there. Then it’s on to Hwangju to assist. It’s all hands on deck as everyone participates in the completion of the Hwangju water project. By 7 PM (and in the gathering darkness) the job is done except for back-filling the trenches. As we return to the hotel in Pyongyang and prepare to leave for home, we each have a story to tell of how God worked out the details of our day to a successful ending. Simply amazing. How great is our God!
Contributed by: Dr. Sharon Perry, December 2009
Timely diagnosis of active tuberculosis is a critical component of TB control, because treatment stops transmission as well as disease. Worldwide, the most common method of diagnosis is observation of acid-fast bacilli in a stained sample of patient sputum, a technique developed by Robert Koch near the end of the 19thcentury. While this method is quick and cheap, it misses up to 50% of cases. Growing organism from a patient sample takes more time, but improves
Pediatric TB patients
diagnosis by 30-50%. In addition, a culture is needed before tests for drug resistance can be carried out. In the Western World, routine culture and drug susceptibility tests are the standard of care. With the emergence of multi-drug resistant TB as a global epidemic, world health authorities have recognized the critical importance of developing these resources in every country. The DPRK National TB laboratory project, a collaborative effort undertaken by Christian Friends, Stanford University, and Mercy Corps in cooperation with the Ministry of Public Health, seeks to address this critical gap in the DPRK national TB program.
Since the famines of the mid 1990’s DPRK has experienced a serious resurgence of tuberculosis, a disease that thrives on malnutrition and other immune-compromising illnesses. In 2008, the rate of tuberculosis in DPRK was estimated to be 344 per 100,000 population, ranking it among the highest burden countries in the world. DPRK is also one of the only high burden countries in the world to lack at least one culture laboratory. Plagued by chronic shortages of drugs and laboratory supplies, in recent years, the proportion of patients who have failed an initial regimen of TB drugs, a high-risk group for drug resistance, has been steadily increasing. In the absence of capacity to culture TB and test for drug resistance, the true extent of their need and the drugs needed to control their epidemic cannot be determined.
A nearly completed Lab room
In 2006, a joint WHO/MOPH team designated a 2500 square foot space at the #3 TB Hospital in Pyongyang for development of DPRK’s first national TB culture laboratory. However, the space was never finished due to lack of funding. Following visits in 2008 by MOPH officials to Stanford and by CFK to the laboratory site in Pyongyang, our organizations raised funds to purchase TB diagnostic equipment and supplies and complete needed infrastructure renovations. During an unprecedented month-long visit this past November, CFK construction and installation teams, Stanford laboratory scientists, and their MOPH counterparts remodeled 13 rooms and installed nearly $300,000 in furnishings and diagnostic equipment. By the end of the visit, MOPH physicians successfully tested two culture systems, the first cultures to be processed at the laboratory site. While completion of this project should be envisioned as a 1-2 year scale up operation, and will likely require more fundraising, the November trip signifies a major milestone in a 2-year planning effort. As we return to families and friends for the holidays, there is much for which to be thankful. For we at Stanford, this includes the opportunity to work with CFK, and the many friendships we have formed along the way.
Lab demonstration by BATC scientist
Developing this laboratory is not unlike building a suspension bridge. A good suspension bridge stands as a testament not only to the harmony of structure and function, but also to sheer human organization. Geologists, mathematicians, civil engineers, divers, carpenters, cablers, cooks, and metallurgists—an entire microcosm of human society– assemble from all corners of the globe to camp out in special dormitories where they share colds as well as bathrooms, and learn that problem-solving is not an accident, but a routine. In the end, what builds a bridge is a common vision, and the human organization that unites behind it. Similarly, the legacy of a bridge is realized selflessly in the new connections it makes possible.
In the annals of civil engineering, what is affectionately known as “The Bridge” in San Francisco claims several distinctions that could also be applied to the DPRK national laboratory project: a lot of people said it couldn’t be done; it was funded entirely by voluntary contributions; it stuck to a schedule; and—something that certainly has not happened in bridge building since– it stayed on budget. When the Golden Gate was completed in 1937, its chief engineer, Joseph Strauss, wrote the following stanzas that I would like to dedicate to some very special bridge-builders. To Heidi Linton and the family at CFK, without whose vision, support, faith, and abiding love of the Korean people, the human community needed to build this laboratory, this new bridge of hope for TB patients in DPRK, would not be possible. Like the Golden Gate, may your efforts endure as a breath-taking symbol of the human spirit.
Ask of the steel, each strut and wire,
Ask of the searching, purging fire,
That marked their natal hour;
Ask of the mind, the hand, the heart,
Ask of each single, stalwart part,
What gave it force and power.
High overhead its lights shall gleam,
Far, far below life’s restless stream,
Unceasingly shall flow;
For this was spun its lithe fine form,
To fear not war, nor time, nor storm,
For Fate had meant it so.
From The Mighty Task is Done, by Joseph P. Strauss, Chief Engineer
Golden Gate Bridge and Highway District, May 1937
The Stanford/BATC orientation workshop team
The First LIS Graduating Class!
Contributed by: Heidi Linton, Director of CFK, December 2009.
While the technical team was fully engaged in the last installation at the Kaesong TB Hospital, Dr. Marcia Kilsby and Dr. Ri (one of our North Korean guides) were conducting a week-long workshop on the use of the Lab-in-a-Suitcase (LIS) for a dozen lab professionals who work at four of our supported hospitals. Each day they participated in lectures and hands-on use of all the equipment in the Lab-in-a-Suitcase, learning how each component could help in the diagnosis and treatment of patients served by their hospitals. The lab equipment comes with a solar panel and battery that can be recharged from a variety of sources. With power unavailable at the training site for much of the training time, it was a very realistic test of the capability of the LIS under usual local conditions. Those who participated in the training were delighted to receive a Lab-in-a-Suitcase for their hospital, and a full starter set of supplies. Central authorities are very interested in this practical and useful project and they hope very much that we can find the necessary funding to expand this important project to many other hospitals in the future. Each LIS costs $5,000 and we have been asked to send 200 or more of them if possible.
So we fix our eyes not on what is seen, but on what is unseen. For what is seen is temporary, but what is unseen is eternal.
So we fix our eyes not on what is seen, but on what is unseen. For what is seen is temporary, but what is unseen is eternal.