Here in North Korea where food is often in short supply and people sleep in crowded accommodation with poor ventilation in winter, there is a serious epidemic with an incidence rate of nearly 350 new cases every year per 100,000 population compared to a global average of 38 per 100,000. TB epidemics incubate slowly and may remain undetected as disease quietly spreads through a population. Once an epidemic starts it can take years to get under control as the TB bacteria often remain undetected even as the disease continues to spread amongst the population.

As well as undertaking the major project at the National TB reference lab, CFK is already supplying up to 40% of all supplies – TB medicine and food, (more cans of chicken!) for many of the hospitals and rest homes, as well as new operating theatres like the one we saw in Sariwon. Of course there remain many challenges. 

Overall, I have seen myself what a wonderful job CFK is doing, really on a shoestring. They are one of just a handful of NGOs working in the country and they are very respected as an organisation in North Korea. It is clear that they have a good co-operative working relationship with the right people and government departments, which is enabling them to get things done. But they are also realistic; they don’t make promises they can’t keep. This is all leading to them being involved in new opportunities and new work; hepatitis is the next big challenge and that could be exciting.

CFK make 3 or 4 trips a year like the one I’ve just been on, delivering supplies and checking their projects.  It is not easy to go; it is certainly not a holiday and it takes planning, willingness and flexibility, but for anyone like me who has lived in  and visited South Korea, life above the impermeable 38^th parallel remains a subject of much curiosity. So, to go there is always fascinating – to me it now feels like South Korea did in the ‘60s. 

To have the purpose of visiting CFK’s work and seeing where my donations have been spent is very special; I’ve seen some amazing things and gained a real insight into the working conditions and therefore the value and hard-earned success of this excellent charity.  

On our last day, we visit the National TB Reference Laboratory in Pyongyang.

In collaboration with Stanford School of Medicine and the San Francisco Bay Area TB Consortium, CFK is currently working on a project to renovate and completely equip this lab. The likely cost is estimated at USD 500,000  (of which about $150,000 remains to be raised) including the cost of importing modern equipment and establishing a reliable electricity and water supply. It is hoped that installations, which we inspect, will all be completed by the end of 2009; the next task will be to train laboratory staff in using the new equipment.

The main challenge now facing the TB system in North Korea is that they are unable to qualify to receive medicines needed to treat patients suffering from drug resistant TB strains. This is in part because they are not able to do the complex culture and sensitivity testing needed to accurately diagnose and treat drug resistant TB.  Also, because they cannot provide accurate statistics on the incidence rate, they are not receiving the level of attention needed to attract stable pools of funding for medicines. 

The National TB Reference Laboratory project will mean that North Korea will be able to understand the pattern of TB transmission and prevalence much better as well as to access the necessary supplies of medicine from international funding pools. This will be an important step in substantially reducing the incidence of TB in North Korea. 

Later we visited Ryokpo Guest House in the countryside outside Pyongyang where we have a fabulous lunch – Korean barbeque “bulgogi”; a special meal which we are assured is “beef”. It is very tough…

No need to order breakfast today – they brought me exactly what I had yesterday without asking! Cornflakes, eggs and bacon; perfectly acceptable.

Another excursion to South Hwang Hae Province. Yesterday’s heavy rain has resulted in flooding. Today we pass through a number of places where the road is under a foot of water and the North Koreans are wading stoically through with their bicycles. At one point the road had collapsed completely and we had to cancel our visit to Umpah.

We did manage to visit Sariwon Provincial TB hospital, where we saw the new CFK-supplied operating theatre in use; in advanced TB cases, surgery is required to remove cavities which the body forms. This can contain but not cure the disease.  CFK has renovated and re-equipped a number of old fashioned operating theatres with a resulting increase in successful operations and a reduction in infections post-surgery.

We also see the Sariwon  and Hwangju TB rest homes, the latter most improved since my last visit. Local officials have prioritised the construction and it has been completely rebuilt and fitted out with window frames and roofing material imported from China by CFK. A fine team effort.

The North Korean government has very scarce foreign exchange resources and is not in a position to import supplies for the TB hospitals. Even basic items such as construction materials have to be imported from China and paid for by CFK. This is the cheapest way to do it – these items are not available locally and it would be very expensive to ship from the US.

The hotel is comfortable with cable TV – CNN but no BBC. Downstairs was a large marble lobby, which showed remarkably little wear and tear in the 30 odd years since it was built – there was a photo of Kim Il-Sung and Kim Jong-Il paying a visit many years ago.

As well as arts and crafts aimed at tourists, the lobby shops sell imported essentials such as wine, beer, biscuits, milk powder, soap, batteries and nappies, plus household items like shoes, clocks, vases and so on which appear to be gifts for guides and local friends. These are available for dollars or euros for locals who have the currency.

Today we made an excursion out of Pyongyang to South Hwang Hae Province (Yellow Sea Province) South of Pyongyang. Our party set off down the main highway to Kaesong, which is 160 km away. The road is almost completely straight and almost completely empty. Apart from us, there was the odd speeding limousine and the occasional broken down lorry. The ratio of broken down trucks to functioning ones was remarkably high!

Something you would be hard-pressed to find anywhere else in the world was the occasional cyclist happily bicycling on the inside lane of the opposite carriageway… We ourselves drove up the wrong side of the highway through the Tae Song tunnel after our visit to one TB rest home.

Our comfortable ride came to an abrupt halt outside Sariwon where the road was closed for repairs to a huge bridge. We bumped off up a dirt road, suddenly seeing lots of local people on bicycles smiling at us and large teams repairing the side of the road.

Each province in North Korea has a hospital dedicated exclusively to treating TB patients. Associated with each hospital are a network of rest homes where patients can stay separate from the general population while they complete their lengthy course of treatment.  Today we visited Shinwon Rest Home, Haeju TB hospital, which has new buildings since my last visit; Haeju and Unryul TB rest homes.

Each time, we begin with a meeting at the director’s office, followed by a walk around, a visit to the laboratory and inspection of the store.

Then we  visit some of the patients. They are all sitting on their beds or on the floor and are generally quite friendly, not appearing to be frightened of us unlike the last time I was here. Then I felt they avoided all eye contact as if they might get into trouble for looking at us.

I find the rest homes clean and pleasant places– in order to completely cure the disease, patients need to take a potent cocktail of drugs over a 6 month period, so families visit, meals are cooked, vegetables grown, all generating a real family atmosphere.

CFK is supplying general medicine, food and other practical support to about 20 such hospitals and rural rest homes,  a paediatric TB care facility in Pyongyang and a general paediatric hospital. In addition, the charity supplies general medicines, blankets, food supplements and canned chicken. The chicken is especially popular we are told, and we certainly see cans and cans of it, which I pass up on tasting.  

The charity also supplies plastic greenhouses which are used to grow food year round, small tractors, generators, medical and laboratory equipment. They have also arranged for boreholes to be dug to upgrade the water supply.

In the evening we went to see the Arirang Show, mass gymnastics, where tens of thousands of performers, mostly students, hold up placards in different colours to make a mosaic of pixels behind the arena, where thousands more performers stream around wearing traditional dress (the women) or military uniform (men).

The performance is mainly artistic with little political overlay. Apparently even as recently as 6 months ago there would have been more anti-American and anti-Japanese imagery; This is the same at a number of public buildings we visited, where anti-Japanese, anti-US and anti-Christian propaganda posters had now been removed, having been there for a long time. At tonight’s spectacle, the main focus is reunification, which is presented as a high priority to the people. It is an awesome experience which can only happen in a society where people have a lot of time on their hands which the state can make use of. 

Arriving in Beijing, I take a taxi to the hotel and meet up with the rest of the group for breakfast; I am travelling with Christian Friends of Korea (CFK) – a US non-profit organisation that has been working in DPRK since 1995). There are six of us in total including a team of experts in diagnostics and TB treatment, plus four or five Koreans from the Ministry of Health, taking the opportunity to see the projects.

Heidi [Linton], the indefatigable Director of CFK disappeared off to the North Korean embassy with my passport and photos to get my visa. By 11 a.m. we were in the departure lounge with a collection of returning North Koreans who were loading up with Marlborough and Camel cigarettes, plus a troop of girls in traditional “hanbok” dresses who appeared to be musicians returning from a concert tour.

Arriving in Pyongyang, I see the first sign of change since my last visit – the old-fashioned soviet-style booths with side windows had been replaced by a row of immigration officials in military style uniform facing us as we arrived.

We had to hand over all phones and communication devices but otherwise, little interest was taken in any of our belongings. So although I am incommunicado, it is very noticeable that since I last visited four years ago, all our guides now have cell phones and make full use of the available selection of ring tones and even watch movies on them. Apparently they can call each other, but not receive calls from foreigners, so behind the scenes there are still a lot of rules. Foreigners can buy mobile phones for their local friends, as long as they are paid for in hard currency, euros for preference, in local shops which are extremely popular these days. People also have laptops and there is an infranet for use in N. Korea, but no internet.

Our guides are all full time officials from the Ministry of Health.  By mutual agreement, the guides are to go everywhere with us, so walks down to the river from the Potongang Hotel are fine but not jogging along the river itself – although they probably would have sent someone to accompany me if I had asked! They are hard working, friendly, and keen to help. Some of them have travelled or studied abroad and they all speak good English. They are happy to chat about their families, work and other neutral subjects, and we share many jokes over the course of our visit.

CFK is working with the Ministry of Public Health which oversees the civilian population, so they are our hosts. That night we had what can only be described as a banquet – 10 courses included grilled trout, barbequed beef, and beer, soju (rice wine) and even a bottle of warm Muscadet – very friendly and convivial. 

I didn’t get off to a great start as I missed my flight from London to Beijing – two major accidents on the drive up and my hopes of getting to Heathrow on time melted away. Sterling work behind the scenes saw me booked on another flight and by 11 a.m I was in Frankfurt negotiating an upgrade on the China Airlines flight to Beijing.