1706 NKHUMANITARIAN Category Archives: NGO

Category Archives: NGO


Espionage and humanitarian aid

JUNE 20, 2017 3:22 PM / LEAVE A COMMENT


The practice of governments using humanitarian organisations and its workers as spies is a contravention of international principles and threatens the wellbeing of legitimate aid and development workers. It is seen as a violation of the basic trust between a government and its civic sector.

Posing as a Red Cross worker is against the Geneva Conventions because it puts humanitarian workers at risk and undermines the neutrality of the Red Cross.[1] If it results in death or serious injury in an international armed conflict it is a war crime.[2]

A notorious example of the improper use of the Red Cross emblem was by Colombian military intelligence officers during the 2008 rescue mission to free Ingrid Betancourt and her fellow hostages from the Farc.[3] This action resulted in an apology to the International Committee of the Red Cross (ICRC) by the Colombian President who expressed “regret that this occured”. He said the incident had not been authorised.

Two recent examples of Western governments using humanitarian aid organisations to spy both involve the DPRK.

The first was the use by the U.S. military of a Christian NGO as a front for espionage in the DPRK. The revelation that the Pentagon used an NGO and unwitting humanitarian volunteers for intelligence gathering was the result of a detailed investigation by The Intercept[4] and picked up by main stream media including the Huffington Post.[5] The next seven paragraphs are extracted from The Intercept’s account of its investigation.

On May 10, 2007, during an award ceremony presided over by President George W. Bush to honour the nation’s most accomplished community service leaders, one of the recipients was an evangelical Christian who was the Colorado-based founder of a multimillion-dollar humanitarian organisation.

Kay Hiramine’s NGO, Humanitarian International Services Group, or HISG, won special praise from the president for having demonstrated how, in the aftermath of Hurricane Katrina, a private charity could step in quickly in response to a crisis.

But Hiramine was a Pentagon spy, alleges The Intercept, whose NGO was funded through a highly classified Defense Department program. HISG was established shortly after 9/11, when Hiramine led a group of three friends in creating a humanitarian organisation that they hoped could provide disaster relief and sustainable development in poor and war-torn countries around the world, according to the organisation’s incorporation documents.

In its first two years, HISG was little more than a fledgling faith-based charity. Just after the U.S. invaded Afghanistan, Hiramine and his friends shipped medical supplies to a hospital there. By 2003, HISG had collaborated with a small Pentagon group called the Afghanistan Reachback Office, which was set up to coordinate reconstruction activities.

That same year the Pentagon had set up its highly classified espionage program to increase human intelligence operations abroad. These Defense Department intelligence operations primarily focused on counter terrorism, but the efforts also extended to Iran and DPRK, where the military sought intelligence on those countries’ nuclear programs. It looked for ways to provide cover for these espionage operations and Hiramine’s group was one of several NGOs used by the Pentagon in this way. Some, like HISG, already existed as fledgling organisations, while others were created from scratch by the Pentagon.

At the time the Pentagon’s espionage program launched, HISG had been responsible for many shipments of medical equipment, clothing, and disaster relief supplies around the world. On at least one occasion in the period between 2004 and 2006, Hiramine, through HISG, helped coordinate a humanitarian shipment to DPRK. The Pentagon encouraged Hiramine to develop the NGO’s links with DPRK and tasked Hiramine with gathering the intelligence it needed inside the country using HISG’s access.

In all, HISG operated in more than 30 countries, significantly funded by the Pentagon, until it was disbanded in 2013. Aside from Hiramine and possibly other top executives, it seems that those who worked for HISG were never witting of their involvement in a Pentagon intelligence program, or that Hiramine was working for the U.S. government.

Using humanitarian and aid workers for gathering intelligence has always been risky and the policy of U.S. intelligence agencies on this issue is unclear and equivocal to say the least. At a public hearing of the Senate Select Committee on Intelligence (SCSI) in February 1996, the then Director of Central Intelligence (DCI) testified that it had not been the CIA’s policy or practice for many years to use clergy, journalists, or Peace Corps volunteers as a cover to conduct espionage. However he said that it would be unwise to “foreclose such use altogether”. Since the mid-1970s, use of these groups for operational purposes had required the approval of the DCI.[7]

After hearing from representatives of the groups involved, the committee inserted language in the FY 1997 intelligence authorisation bill stating that it was the “policy of the United States” that journalists would not be used for “purposes of collecting intelligence.” However, the new law provided that the president or the DCI could waive this policy, so long as the two intelligence committees were advised. The law also said it should not be construed to prohibit “the voluntary cooperation of any person.” This action essentially left in place the existing policy with respect to operational use of clergy and Peace Corps volunteers.[7]

It appears that this policy was loosened significantly in counter-terrorism efforts after the 9/11 attacks.[8] In any case, except for American Peace Corps volunteers, the policy did not include humanitarian and aid workers working for U.S. non-profits and other NGOs.

In recent years, the risk of using legitimate aid workers as cover for spying has had deadly repercussions.

In 2011, the CIA directed a Pakistani doctor to collect DNA samples of the suspected family members of Osama bin Laden under the guise of a hepatitis vaccination program in Abbottabad, Pakistan. After the raid, the Pakistani doctor was arrested and imprisoned by Pakistani authorities, and the Taliban later killed several medical professionals who were trying to conduct polio eradication campaigns, along with their guards. The Taliban claimed the vaccination program was part of a Western intelligence plot.

As The New York Times reported in 2012, a further reaction to the CIA operation has been that vaccination teams were banned in some areas of Pakistan.[9] A consequence of CIA actions is that cases of polio, which has been eradicated in almost every country in the world, have spiked in Pakistan in recent years.

In January 2013, the deans from Tulane, Emory, Columbia and other U.S. universities wrote to President Obama about the assassination of vaccination workers. They also compared the use of vaccine programs to the CIA’s early infiltration of the Peace Corps, saying that in both cases, the practice had to be stopped to protect volunteers and gain access where people are most vulnerable to disease. As a result of this pressure, a White House Homeland Security adviser informed U.S. public health school deans in 2014 that CIA Director John Brennan had issued an order in August 2013 forbidding the use of vaccination programs as cover to gather intelligence or genetic evidence.[10]

It would have been hoped that other Western countries might follow the U.S lead on this. However the second and very recent example of governments using humanitarian aid organisations to spy involves another U.S. Christian NGO but this time one that operates out of South Korea.

Unlike the discredited and now disbanded HISG, the Eugene Bell Foundation (EBF) has gone public to express its unhappiness that NGOs in South Korea have been “grabbed by the collar” by the ROK government to act inappropriately when operating in DPRK.

In June 2017, NK News (see the full story here) reported that the South Korean government has asked non-governmental organisations to submit “unfair” reports on North Korea, including confidential information on local patients, in exchange for approving humanitarian aid exchanges with the DPRK.

Speaking at a news conference in June 2017, held after a three-week trip to DPRK, Stephen Linton, Chairman of the Eugene Bell Foundation, said Seoul was asking for sensitive information from NGOs that many were not comfortable handing over.

EBF was also asked to provide information on North Korean patients assessed by the DPRK Ministry of Public Health, as well as general information from inside the country, Linton said.

“I could endure [the government agency] asking about the North Korean situation,” he told media. “But I think it’s unfair that they asked whether [North Korean people] have changed their thoughts about the leader, or if there is anything peculiar that wasn’t covered by newspapers.”

Eugene Bell program director Jinnie Hong explained that the Ministry of Unification (MoU)’s Humanitarian Assistance Division was insisting it could only approve shipments of medical supplies once a “completed” report was provided, and that they faced “deadlock” with the South Korean goverment over this.

The Eugene Bell Foundation is a Christian charitable organisation registered in the U.S. that seeks to meet the special needs of citizens of the DPRK at home and abroad. It sponsors programs, projects and exchanges of a humanitarian nature with a focus on medicine and the diagnosis and treatment of tuberculosis (TB) in particular. We have posted previous articles on the rising rates of TB in the DPRK here and here and with EBF’s work to combat it here and here. This latest incident is not the first time EBF has experienced difficulties working through the South Korean government.

The NGO visited DPRK from May 2 to May 23, 2017, to treat North Korean patients with multidrug-resistant tuberculosis (MDR-TB), six months after a visit in Autumn 2016, a trip during which the NGO, with permission from the U.S. government, provided resistance testing GeneXpert machines to North Korean doctors.

The DPRK Ministry of Public Health has also “officially requested” that the foundation expand its assistance project to the east coast region of North Korea, and Linton is planning to send prefabricated hospital wards engineered to prevent the spread of the infectious disease to the North, which will be delivered this summer.

Linton said that NGOs in South Korea had been “grabbed by the collar”by the government, arguing that South Korean intelligence had too much say in permitting visits to the North and over NGO work.

“I would like to ask a favor of [the Moon Jae-in government] that another agency should control the activities of the NGO, not the organisation who is interested in espionage,” Linton said.

He added that the civilian exchanges would be “meaningless” if South Korean intelligence had “absolute authority” over NGO projects.[6]

Sources

[1] Article 38(1) of the 1977 Additional Protocol I provides: “It is prohibited to make improper use of the distinctive emblem of the red cross, red crescent or red lion and sun.”

[2] Under Article 8(2)(b)(vii) of the 1998 ICC Statute, “[m]aking improper use … of the distinctive emblems of the Geneva Conventions, resulting in death or serious personal injury” is a war crime in international armed conflicts.

[3] https://www.theguardian.com/world/2008/jul/16/colombia

[4] https://theintercept.com/2015/10/26/pentagon-missionary-spies-christian-ngo-front-for-north-korea-espionage/

[5] http://www.huffingtonpost.com/entry/pentagon-missionary-spies-north-korea_us_562d5421e4b0aac0b8fd44a9

[6] https://www.nknews.org/2017/06/rok-govt-demanding-unfair-report-on-n-korea-in-exchange-for-visits-ngo/

[7] https://www.cia.gov/library/center-for-the-study-of-intelligence/csi-publications/books-and-monographs/agency-and-the-hill/11-The%20Agency%20and%20the%20Hill_Part2-Chapter8.pdf

[8] Partly Cloudy: Ethics in War, Espionage, Covert Action, and Interrogation. 2016. David L. Perry, Rowman & Littlefield. p. 157.

[9] http://www.nytimes.com/2012/07/10/health/cia-vaccine-ruse-in-pakistan-may-have-harmed-polio-fight.html?_r=1&pagewanted=all&

[10] http://www.npr.org/sections/thetwo-way/2014/05/20/314231260/cia-says-it-will-no-longer-use-vaccine-programs-as-cover


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South Korea lacks a “mature humanitarian policy”

JANUARY 24, 2017 5:02 PM / LEAVE A COMMENT


Speaking at a news conference in December 2016 after returning from a three-week visit to the DPRK, Stephen Linton, Chairman of the Eugene Bell Foundation (EBF), said South Korea’s Ministry of Unification (MoU) lacked a “mature humanitarian policy.”

“I went to the Ministry of Unification a few days ago”, he said, “and asked their permission to ship the first round of [medical supplies] in 2017, but their answer wasn’t favorable, saying ‘not now, and please wait.'”

Recalling that an official from the MoU pledged at a meeting in August that they would ensure the foundation could send MDR-TB drugs to North Korea ‘without any problems’, Linton said he “asked whether our [verbal] promise was broken, but they gave us an absurd answer, [telling me] I could ‘go and ask Kim Jong Un’ [the reason for not approving the shipment].”

Linton pointed out that the medical supplies had to be loaded in January, despite the MoU’s claims the foundation could wait until March, April or May. Any delay, Linton said, “increases the possibility that [the drugs] may arrive [in the North] after our visit in May,” noting that “if our patients run out of drugs and develop increased drug resistance, they are likely to die. We must avoid this.” [Editor’s Note: On 17 January the MoU finally allowed the Eugene Bell Foundation to ship the delayed multidrug-resistant tuberculosis (MDR-TB) medication to the DPRK.]

Linton is on record as arguing that humanitarian aid should continue regardless of North Korean provocation and political strife between the two Koreas. This latest setback for EBF followed an earlier incident in 2016 when it took weeks of pressure from EBF before authorities in Seoul would issue permits for the export of three containers of desperately needed specialist medical supplies destined for the ongoing treatment of MDR-TB sufferers in Eugene Bell Foundation supported clinics in the North.

EBF pointedly stated at the time that the ROK government had failed to make humanitarian aid an exception to the additional sanctions against the DPRK it announced in March of that year and that the lives of more than 1,500 North Korean MDR-TB sufferers were at risk because of this.

Original story and reporting by Dagyum Ji in NK News here.

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South Korea approves 2017’s first humanitarian aid shipment to DPRK

JANUARY 19, 2017 5:25 PM / 1 COMMENTON SOUTH KOREA APPROVES 2017’S FIRST HUMANITARIAN AID SHIPMENT TO DPRK


South Korea’s Ministry of Unification (MoU) on January 17 approved humanitarian aid to DPRK for the first time this year.

The MoU said it would allow the nonprofit Eugene Bell Foundation to ship multidrug-resistant tuberculosis (MDR-TB) medication to the DPRK.

At a regular news briefing, the Unification Ministry said the government’s stance on humanitarian aid remained “unchanged.”

“Our basic position is to continue to provide humanitarian aid for the vulnerable including infants and pregnant women,” a spokesman said.

Stephen Linton, Chairman of Eugene Bell Foundation, previously said that the MoU had suggested it would not allow the shipment to go ahead.

At a news conference on December 22, Linton said that an MoU official had told him that he could “go and ask Kim Jong Un” about the reason for the disapproval.

When Linton accused the MoU of lacking a “mature humanitarian policy,” the MoU insisted the government was “positively considering” his request.

Linton declined to directly comment on Tuesday’s news.

“All we can reveal is that we hope to send our medications the end of Feb or beginning of March, that we hope to visit in May,” Linton told NK News. “And that we will continue to encourage positive consideration of our patient ward project because infection control is an important part of treatment.”

Despite the MoU granting permission for the medication to be shipped, another Eugene Bell request for the shipment of construction materials to build medical facilities in Pyongyang – originally submitted on December 20 – might not be approved by the government.

Linton said he planned to build “at least 60 units of a sanitarium” to treat tuberculosis in the Sadong District of Pyongyang in 2017 at a news conference back in December.

Eugene Bell, in coordination with South Korean company SY TECH, has been designing prefabricated treatment camps in the North, Linton added, and hopes to bring them to North Korea this year.

Full story from NK News on these latest aid shipments here.

Editor’s note: The MoU approved humanitarian aid from Eugene Bell twice last year. It is the only NGO based in the South which was allowed to send help directly to the North in 2016.







Eugene Bell is the only NGO based in the South which sent help to the North in 2016.

JANUARY 19, 2017 4:41 PM / 3 COMMENTSON EUGENE BELL IS THE ONLY NGO BASED IN THE SOUTH WHICH SENT HELP TO THE NORTH IN 2016.


NK News reports that on 17 January, South Korea’s Ministry of Unification (MoU) approved 2017’s first humanitarian aid shipment to DPRK. The MoU said it would allow the nonprofit Eugene Bell Foundation to ship multidrug-resistant tuberculosis (MDR-TB) medication to the DPRK.

Other South Korean NGOs questioned the “fairness” of MoU decision. The MoU approved humanitarian aid from Eugene Bell twice last year, and it is the only NGO based in the South which sent help to the North in 2016.

In contrast, the MoU disallowed the Korea NGO Council for Cooperation with North Korea (KNCCK) from meeting the North Korean side in a third country to discuss flood repair cooperation in September.

As a result, KNCCK, a confederation of 54 local nongovernmental organizations, sent relief funds for flood victims to the International Red Cross (IRC).

“It’s a good thing that Eugene Bell can still provide support… But we also are considering the issue of fairness, which is obvious to everyone,” Kwak Young-joo, a representative of KNCCK, told NK News.

“South Korean NGOs providing aid to the North are ready to send support, but we’ve suspended our activities for a long time,” Kwak said. “I am frustrated, but I am expecting to see changes this year.”


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Sanctions against the DPRK threatens to make the lives of the most vulnerable even worse

APRIL 24, 2016 9:41 AM / LEAVE A COMMENT


In an October 2013 article in East Asia Forum, academic and NGO field worker Emma Campbell argued that the sanctions regime in place to curtail the DPRK’s nuclear program, and to tackle the appalling human rights record, threatens to make the lives of the most vulnerable even worse.

Laying responsibility for the DPRK’s current predicament squarely at the feet of the North Korean regime, she reminds us, however, that this is a “world of international rights and norms.” When constructing policy toward the DPRK she notes, “there is a responsibility to prevent a worsening of the plight of the North Korean people. It appears that the ongoing sanctions regime is failing in this.”

The article gave examples of the perverse and chilling effects on humanitarian aid efforts in the DPRK caused by the unintended consequences of sanctions, particularly sanctions targeted at banks dealing with the DPRK. Sadly, her description of the effects of sanctions in 2013 “constraining the actions of humanitarian NGOs trying to carry out life-saving activities inside the DPRK” are still having the same effect in 2016.

The most recent example of this has just been played out in South Korea where delays by the ROK government in granting permits to export three containers of essential specialist medical supplies, threatened the lives of 1,500 MDR-TB patients in the North who are being treated in clinics supported by the Eugene Bell Foundation (EBF). This sorry tale and its outcome can be followed on this blog here and here.

To underscore the difficulties NGOs can face, there is a telling comment in a leaked confidential internal EBF memo, dated 19 February 2016. In the memo, EBF said it had another option: to purchase the medications on the international market instead of from the Republic of Korea and to have them shipped directly to the DPRK. This would obviate the need to apply for ROK export permits but would also create a host of other potential problems, EBF noted. Not least of these being that EBF would have to wire funds from its bank accounts to foreign entities to pay for shipments to North Korea. Non-Korean pharmaceutical companies would probably refuse to take EBF’s order as doing so could be a technical violation of sanctions.

The concern expressed by EBF about possible “technical violation of sanctions” had been reinforced the previous day when the North Korea Sanctions and Policy Enhancement Act of 2016 was signed into law on February 18 by President Obama.

It has been noted by legal experts on sanctions that the Act would implement extraterritorial ‘secondary sanctions’ that could impact a variety of importers and exporters, and potentially other companies such as freight forwarders, vessel owners, and insurers who do business in countries that engage in trade with North Korea, such as China. The threats to humanitarian efforts in the North have likely worsened as a result.



Seoul finally approves delayed humanitarian shipment to the DPRK
MARCH 30, 2016 12:30 PM / 2 COMMENTSON SEOUL FINALLY APPROVES DELAYED HUMANITARIAN SHIPMENT TO THE DPRK


MEDICINE SUPPLIES STACKED IN CONTAINERS ARE SEEN AFTER SHIPMENTS TO NORTH KOREA WERE DELAYED AT A PORT IN PYEONGTAEK, SOUTH KOREA, FEBRUARY 25, 2016, IN THIS HANDOUT PHOTO RELEASED BY THE EUGENE BELL FOUNDATION. REUTERS/EUGENE BELL FOUNDATION/HANDOUT VIA REUTERS

The Eugene Bell Foundation (EBF) said on March 25, “Despite tensions on the Korean Peninsula, medical aid and other related supplies to fight multidrug-resistant tuberculosis have successfully reached the North.”

The announcement followed weeks of pressure on authorities in Seoul to issue permits for the export of three containers (see above) of desperately needed specialist medical supplies destined for the ongoing treatment of MDR-TB sufferers in Eugene Bell Foundation supported clinics in the North.

In a March 9 press release, the Eugene Bell Foundation said that the lives of more than 1,500 North Koreans are at risk because the ROK government failed to make humanitarian aid an exception to the additional sanctions against the DPRK it announced on March 8 – see full story on this blog here.

EBF also added that its representatives will make a planned visit to the DPRK from April 19 to May 10 in order to inspect the treatment of the patients and the overall situation there.


THIS UNDATED HANDOUT PHOTO PROVIDED BY THE EUGENE BELL FOUNDATION (EBF), SHOWS JOHN ROGERS, EXECUTIVE DIRECTOR OF THE EUGENE BELL FOUNDATION, RIGHT, PREPARING TO DISTRIBUTE TUBERCULOSIS MEDICATION TO PATIENTS AT A TB TREATMENT CENTER IN RYOKPO, NORTH KOREA. DESPITE WORSENING U.S.-NORTH KOREAN RELATIONS, AN AMERICAN CHARITY IS RAMPING UP EFFORTS AGAINST AN EPIDEMIC OF MULTIDRUG-RESISTANT TUBERCULOSIS IN THE ISOLATED COUNTRY, WHERE IT SAYS IT IS MAKING INROADS IN FIGHTING THE DEADLY DISEASE. THE EUGENE BELL FOUNDATION TRAVELS TO NORTH KOREA TWICE-A-YEAR, BRINGING HIGH-END EQUIPMENT AND DRUGS TO TREAT PATIENTS AT OLD-WORLD SANATORIA THAT HOUSE SUFFERERS OF TB THAT HAS SPREAD AMONG A POPULATION WEAKENED BY MALNUTRITION SINCE A FAMINE IN THE 1990S. THE FOUNDATION GOES AGAIN THIS MONTH, ON A WHIRLWIND, THREE-WEEK MISSION TO HELP HUNDREDS OF PATIENTS.(AP PHOTO/EUGENE BELL FOUNDATION)







Eugene Bell Foundation declares medical emergency: Lives of more than 1,500 North Korean MDR-TB patients at risk because South Korea blocks humanitarian aid

MARCH 15, 2016 10:27 PM / 3 COMMENTSON EUGENE BELL FOUNDATION DECLARES MEDICAL EMERGENCY: LIVES OF MORE THAN 1,500 NORTH KOREAN MDR-TB PATIENTS AT RISK BECAUSE SOUTH KOREA BLOCKS HUMANITARIAN AID


MEDICINE SUPPLIES STACKED IN CONTAINERS ARE SEEN AFTER SHIPMENTS TO NORTH KOREA WERE DELAYED AT A PORT IN PYEONGTAEK, SOUTH KOREA, FEBRUARY 25, 2016, IN THIS HANDOUT PHOTO RELEASED BY THE EUGENE BELL FOUNDATION. REUTERS/EUGENE BELL FOUNDATION/HANDOUT VIA REUTERS

Essential humanitarian aid to treat multi-drug resistant TB (MDR-TB) in the DPRK has been held up in South Korea because of the imposition of new sanctions.

In a March 9 press release, the Eugene Bell Foundation (EBF) said that the lives of more than 1,500 North Koreans are at risk because the ROK government failed to make humanitarian aid an exception to the additional sanctions against the DPRK it announced on March 8.

EBF appealed to Seoul authorities for rapid action to release the three containers of MDR-TB medication destined for the 1,500 patients enrolled in treatment programmes in its twelve treatment centres in the DPRK. These have just enough of the medication to last through April.

“Unless something is done quickly, our patients will fail treatment and die” said Dr. Stephen Linton, Chairman of the Eugene Bell Foundation.

These patients are infected with highly resistant strains of TB that are untreatable with standard TB drugs. The 1,500 patients in the DPRK must complete an 18-month course of treatment with the EBF-supplied medication to fight this dangerous disease. The press release warns that interruption in treatment puts patients at risk of developing extensively drug resistant (XDR) TB with its fatal consequence. Family members who come in contact with a dying XDR-TB patient will be at risk of contracting this very dangerous ‘super-TB’ too.

The press release notes that “most of the funding for the [MDR-TB treatment] program comes from voluntary contributions by South Korean citizens and Koreans living overseas. Until this spring, Eugene Bell has been a dependable conduit for non-political, transparent medical assistance targeting the most serious public health challenge facing the Korean peninsula.”

Additional material on this story is provided by NK News here.

Editor’s Notes
Emergency humanitarian aid to save lives is an exception to UN sanctions and should not be prevented from being delivered.
The Eugene Bell Foundation (EBF) and Christian Friends of Korea (CFK) are the two NGOs that provide critical medical humanitarian assistance to the DPRK. Both have worked continuously in the DPRK for more than 20 years. They have earned a reputation for delivering on promised assistance and have come to be viewed by their counterparts in the DPRK as reliable[1].
In a private memo dated February 19, 2016, which was not meant for public dissemination, the CEO of the Eugene Bell Foundation was clear about the consequences of further delay by Seoul in granting the export permit for the three containers of MDR-TB medication destined for the DPRK:

“… not only are the lives of our patients now at risk, but also a 20-year legacy of humanitarian trust-building…. If our export permit is delayed indefinitely, our program will become a humanitarian disaster with our patients running out of medications and developing additional drug resistance before dying. Clearly this would not be in the interest of either the Republic of Korea or the United States or the international community”[2].



References

[1] Snyder, Scott (2007). “American Religious NGOs in North Korea: A Paradoxical Relationship.” Ethics and International Affairs, November 15. http://www.ethicsandinternationalaffairs.org/2007/american-religious-ngos-in-north-korea-a-paradoxical-relationship-full-text/

[2] Eugene Bell Foundation (2016). “Confidential Update, February 19, 2016”. http://drive.google.com/file/d/0BzrVi_cte9AoZTNiWVotRkMxS2s/view?usp=sharing









Hepatitis B in the DPRK: A serious health problem

FEBRUARY 29, 2016 11:24 PM / 1 COMMENTON HEPATITIS B IN THE DPRK: A SERIOUS HEALTH PROBLEM




Dr. Alice Lee, a gastroenterologist and hepatologist from Australia, visits a teenage patient at Kaesong #2 Hepatitis Hospital (May 2015). Dr Lee led Christian Friends of Koreas’s efforts to begin a hepatitis B survey and vaccination project among health care workers at CFK’s supported facilities in the DPRK[2].

Hepatitis B is a viral infection that attacks the liver and can cause both acute and chronic disease. It is a major global health problem which can cause chronic infection and puts people at high risk of death from cirrhosis and liver cancer.

The virus is transmitted through contact with the blood or other body fluids of an infected person. For this reason hepatitis B is an important occupational hazard for health workers.

An estimated 240 million people worldwide are chronically infected with hepatitis B. More than 780,000 people die every year due to complications of hepatitis B, including cirrhosis and liver cancer.

There is still limited access to diagnosis and treatment of hepatitis B in resource-constrained settings, such as the DPRK, and many people are diagnosed only when they already have advanced liver disease. Liver cancer progresses rapidly, and since treatment options are limited, the outcome is in general poor. In low-income settings, most people with liver cancer die within months of diagnosis.

However, hepatitis B can be prevented by a currently available safe and effective vaccine. The vaccine against hepatitis B has been available since 1982. It is 95% effective in preventing infection and the development of chronic disease and liver cancer due to hepatitis B. Unfortunately, many ‘at risk’ people in the DPRK, particularly health care workers, are yet to be vaccinated.

Hepatitis B is endemic in the DPRK. It is an important public health problem because of its high prevalence combined with the often deleterious chronic course noted above that leads to both physical impairment and suffering of the patients as well as causing a huge socio-economic burden[3].

It is assumed that the transmission of hepatitis B in the DPRK occurs mostly from mother to child at birth (perinatal transmission) or through horizontal transmission such as reuse of needles in health-care settings or exposure to infected blood. The latter is often from an infected child to an uninfected child during the early years of life. Sexual transmission of hepatitis B may also be an important factor[1][3].

Obtaining epidemiological data on diseases or health related problems in the DPRK is difficult so the prevalence of hepatitis B can onlybe estimated. The World Health Organization (WHO) calculated a prevalence of 4.5% in 2003. Anecdotal evidence and unpublished data from a survey among North Korean refugees in South Korea, suggests that a prevalence of 9% is more realistic. Given the high natural incidence of hepatitis in East Asia of up to 20%[4], and the North Korean deficits in vaccination, the true prevalence can be assumed to be even higher[3].

The management of hepatitis B in the DPRK has been very limited despite an extensive state-funded health care structure with specialized “Hepatitis Hospitals” in each governmental district. The current treatment of hepatitis B and its complications, such as liver cirrhosis and liver cancer, has consisted of traditional herbal medicine. Effective antiviral agents have been available for many years outside of the DPRK, as well as drugs to treat liver disease complications, but they are known to relatively few physicians in the coutntry and those have no experience with these treatments[3].

One reason hepatitis B became endemic in the DPRK was because there was no comprehensive vaccination programme in the country until 2004. That is when the national immunization program included nationwide hepatitis B vaccination of newborn. However, this still left a gap of 3.8 million unvaccinated children born before 2004.

As part of a bi-modal strategy to deal with hepatitis B and its associated problems in the DPRK, Caritas Germany worked with the Ministry of Public Health of North Korea (MoPH) to close this huge gap of unvaccinated children by vaccinating more than 3.7 million North Korean children aged from 6 to 16 during the period 2010 to February 2012. According to the MoPH, this catch-up vaccination campaign covered 99.3% of the unvaccinated children in the DPRK[4].



Caritas catch-up vaccination programme in the DPRK (July 2011)[6]

A notable feature of this vaccination campaign was its funding by South Korea who provided vaccines worth US$2.37 million to Caritas. It was interrupted twice as tensions between North and South escalated and the vaccinations only continued after heavy lobbying of South Korean politicians by the German NGO[5].

The hepatitis B vaccine remains the mainstay of hepatitis B prevention. The vaccine has an excellent record of safety and effectiveness. WHO recommends that all infants receive the hepatitis B vaccine as soon as possible after birth, preferably within 24 hours. The birth dose should be followed by 2 or 3 doses to complete the primary series[1].

The complete vaccine series induces protective antibody levels in more than 95% of infants, children and young adults. Protection lasts at least 20 years and is probably lifelong[1]. Being able to maintain its national immunization program of the newborn, including the hepatitis B vaccination, is of vital importance to the DPRK if it is to ever overcome the endemic health problems of tuberculosis and hepatitis B.

For the less than 1% of immunized children who later develop chronic hepatitis B, and those of older, unvaccinated, generations who have developed acute hepatitis B, there is no cure. Treatment options depend on the severity of the disease.

There is no specific treatment for acute hepatitis B. Therefore, care is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids lost from vomiting and diarrhoea[1].

Chronic hepatitis B infection can be treated with drugs, including oral antiviral agents. Treatment can slow the progression of cirrhosis, reduce incidence of liver cancer and improve long term survival. In most people, the treatment does not cure hepatitis B infection, but only suppresses the replication of the virus. Therefore, most people who start hepatitis B treatment must continue it for life[1].

The oral anntiviral agents rarely lead to drug resistance as compared with other drugs, are simple to take (1 pill a day), and have few side effects so require only limited monitoring[1]. They are “finally within the reach of the DPRK”[2], according to the U.S. based charity, Christian Friends of Korea (CFK). However the need for life-long treatment has obvious implications in countries like the DPRK, where treatment continuity will be extremely vulnerable to disruption, as happened with the 2010-2012 hepatitis B vaccination catch-up programme described earlier.

CFK has been working in the DPRK for some years in close collaboration with the country’s Ministry of Public Health (MoPH). The charity’s original focus was on the clinical aspects of tuberculosis (TB), helping the country to improve its treatment and testing facilities, including providing equipment and ongoing training for the National TB Reference Laboratory. Some years ago it was invited to also provide general support for hepatitis care centres. The initial support included greenhouses, water systems, supplemental food and medicine, tractors, blankets, etc. Starting in May 2015, CFK began addressing the more clinical aspects of hepatitis B prevention and teatment in the DPRK[2].

It immediately identified a need for a hepatitis B vaccination programme among health care workers who staff the approximately 150 sanatoriums around the country treating tuberculosis and hepatitis B patients. These care workers were born well before 2004 and were too old to be included in the 2010-2012 vaccination catch-up programme for 6-16 year olds.

For North Koreans already infected by the hepatitis B virus, CFK’s plans for the future could offer some of the medical support we take for granted in Europe: “In the near term, we hope to start a pilot project to support anti-viral therapy, while also strengthening diagnostic and treatment capability by expanding emergency intervention, nutritional support and palliative care to people already suffering from more advanced liver disease. A proposal and negotiations for a new hepatitis prevention and care plan was approved and signed by the Ministry of Public Health.

“This is a long-awaited and urgent priority that promises to bring hope and healing to many lives. From this beginning, we will negotiate a fuller Memorandum of Understanding on a future visit that will guide our efforts going forward”[2].

CFK’s committment to the DPRK is commendable. It should be inspiring other humanitarian NGOs, particularly those specialising in health care, to follow CFK’s example. However, without long-term support from major international donors and other aid organisations, leaving a single U.S. based donor with the responsibility for essential treatment, supplies, training and operational expertise, creates the risk that programmes, supply lines, testing and treatment will be interrupted.



NOTES

[1] WHO Fact sheet No. 204 (July, 2015). http://www.who.int/mediacentre/factsheets/fs204/en/#

[2] CFK Newsletter. (June 2015). http://cfk.org/wp-content/uploads/2015/06/June-2015-Newsletter-Final-PROOF.pdf

[3] Fighting hepatitis B in North Korea: Feasibility of a bi-modal prevention strategy. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4630473/

[4] Hepatitis B infection: Current concepts and future challenges. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259419/

[5] Yonhap News Agency (2013). Nearly 4 million N.K. children vaccinated against hepatitis B. http://english.yonhapnews.co.kr/northkorea/2012/03/13/21/0401000000AEN20120313001700315F.HTML

[6] Caritas (2011). http://www.caritas.org/where-we-are/asia/korea/


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TB rates on the rise in the DPRK warns NGO

FEBRUARY 23, 2016 3:28 PM / 5 COMMENTSON TB RATES ON THE RISE IN THE DPRK WARNS NGO


Christian Friends of Korea (CFK) warns that TB rates are on the rise in North Korea. CFK works closely with the country’s Ministry of Public Health (MoPH) to plan and deliver important screening and treatment facilities for two serious endemic diseases that effect a significant number of people in the DPRK: Hepatitis B and Tuberculosis (TB), including multidrug-resistant TB (MDR-TB).

Of its battle with TB the charity said in December 2015: “While we see much progress, especially at the individual institutions where we work, tuberculosis (TB) rates are continuing to rise countrywide. The World Health Organization 2015 report indicates TB incidence in the DPRK is now more than 442: 100,000 and rising. We heard in our travels that active case finding is underway, meaning that household doctors are more actively working to find new cases, and hopefully, treat them. But many of the same underlying factors of poverty and malnutrition are still present, including lack of clean water and sanitation, close living quarters, weakened immune systems, and systemic health sector weaknesses which are all contributing to the still-rising epidemic of TB. Our practical support is still greatly needed, and it is saving many lives every year.”

For more information about CFK’s current work in the DPRK, see its December 2015 Newsletter here.