Doctor O Yong Il swings open a glass door with a bright orange biohazard sign and gestures to the machine he hoped would revolutionize his life's work. It's called the GeneXpert and it's about the size of a household microwave oven. As chief of North Korea's National Tuberculosis Reference Laboratory, Dr. O saw it as a godsend.
Tuberculosis is North Korea's biggest public health problem. With this American-made machine, his lab would be able to complete a TB test in just two hours, instead of two months.
It took years, but Dr. O got the machines, only to discover that GeneXpert needs cartridges he can't replace. It's not entirely clear what about the cartridges would violate international sanctions. For a long time, the producer refused to disclose what agents were inside because that was patented information. But it doesn't really matter. No one, it seems, is willing to help him procure them from abroad and run the risk of angering Washington.
Despite a budding mood of detente on the Korean Peninsula since the summit between President Donald Trump and North Korean leader Kim Jong Un last month in Singapore, ongoing sanctions championed by the U.S. and Trump's "maximum pressure" policy continue to generate an atmosphere of hesitation and the fear of even unintentional violations. And that is keeping lifesaving medicines and supplies from thousands of North Korean tuberculosis patients.
Dr. O's laboratory, built with help from Stanford University and Christian Friends of Korea aid group, has essentially been running on empty since April.
But the idle GeneXperts may soon be the least of his troubles.
Tuberculosis kills more than 1.6 million people a year. When left untreated it will be fatal in half of those it infects. It's the world's most deadly infectious disease and is so contagious that each case can be expected to lead to 10 to 20 more.
In developed countries, it has largely been brought under control. There's a vaccine that prevents it and a cocktail of drugs that can be used to treat, and often cure, it in a matter of months. But it's a major scourge in less affluent places, including North Korea and sub-Saharan Africa.
To help North Korea control its tuberculosis problem, a Geneva-based international aid organization called the Global Fund to Fight AIDS, Tuberculosis and Malaria has dispersed more than $100 million in grants since 2010. Last year it supported the treatment of about 190,000 North Korean TB patients.
But, two weeks ago, Global Fund ended all of its North Korea-related grants, saying it could no longer accept the North's "unique operating conditions." Spokesman Seth Faison said the fund informed Pyongyang in February so it would have time to look for alternative funding sources. He said Global Fund is providing buffer stocks of medicines and health products to help support the treatment of tuberculosis patients through June next year.
Faison said Global Fund welcomes the "positive diplomatic efforts underway" between Pyongyang and its neighbors. But the fund's position stands.
The decision shocked the doctors at the Pyongyang tuberculosis lab, who praised Global Fund for the work it had done but accused it of bowing to political pressure from the United States and Trump's vow to keep the pressure on and not ease sanctions until the North makes major steps toward denuclearization. The United States government, which has pledged $1.4 billion this year, is one of Global Fund's biggest donors.
The fund's retreat sparked outrage outside of North Korea as well. In an open letter published in the medical journal Lancet, Harvard physician Kee Park, director of North Korea programs for the Korean American Association, warned the fund's withdrawal could create a "humanitarian and public health crisis" and called the move "a cataclysmic betrayal of the people of the DPRK."
Whatever the reason, its departure is valid cause for concern.
When tuberculosis patients reduce or go off their medications prematurely, or begin taking lower quality ones, the bacteria that causes their disease can develop a resistance to the two most powerful anti-TB drugs, making the condition harder and much more expensive to treat. This kind of multi-drug resistant TB is most often found in China, India and Russia.
And it's a big problem in North Korea.
North Korea's health system is fragile and strapped for resources. But in keeping with Kim's directives to lift the nation's standard of living, officials are looking for ways to improve.
"We have been waging a vigorous struggle with a highly ambitious plan to increase the average life expectancy of the population and bring other health indices in line with those of the world's most advanced countries," explained Ri Jong Chang, who is the director of the Central Tuberculosis Prevention Institute and has worked with TB patients for the past 25 years.
Ri explained that at the most basic level, the country maintains a network of about 7,000 clinics and a system initiated decades ago that focuses on "household doctors." Each doctor is responsible for the care of 150 households within their administrative area. Along with primary care, they keep their patients informed and educated about health issues and conduct activities to prevent diseases.
If a suspected case of tuberculosis is found, the patient is sent to a county-level hospital for testing.
Aware of its needs and vulnerabilities, North Korea, which is generally secretive and deeply suspicious of anything that smacks of foreign "meddling," has demonstrated a surprising willingness to accept help, allow access and share information with United Nations' agencies and foreign aid organizations.
Along with Global Fund, the most established group treating TB patients in the North is the Eugene Bell Foundation, which supports the treatment of more than 1,000 patients at 12 centers across the country. Unlike Global Fund, since 2008 the Eugene Bell Foundation has been solely focused on fighting multi drug-resistant tuberculosis, which typically takes about 18 months to treat and costs nearly $5,000 per patient.
Stephen Linton, who founded the group in 1995, has a grim assessment of the situation.
"We are probably only covering about one-tenth of the MDR-TB patients in the country right now," he told The Associated Press.
He said about half of his patients are in Pyongyang, a city of 3 million and the place where most of the North's elites reside. The reason is straightforward — MDR-TB develops after exposure to medications that failed. In rural areas, fewer people have access to those medicines to begin with.
"If you are living in the countryside in North Korea, you are much less likely to get MDR-TB than if you live in Pyongyang. It's horrendous," he said. "We can't get to the bottom of it, even though we focus a lot of resources there."
What really worries him, and the North Korean government, is what will happen if the patients who relied on Global Fund support run out of medications, stop getting help or turn to cheaper, less effective treatments.
Many will die. But not before infecting many others.
"This is an airborne infection," he said. "Every time you are in a closed space with a TB patient, you are at risk. So for all the people that travel to North Korea, all the tourists, all the diplomats — they are a risk to everyone who comes near them."
This was supposed to be the year Eugene Bell began to really up its game in North Korea, tripling to 3,000 the number of patients it treats.
Many of the sanatoria where TB patients are treated in the North were built 30 or 40 years ago. They have poor insulation, are overcrowded and are often fire hazards. To address those problems and the sort of transparency issues Global Fund was concerned about, Eugene Bell has developed pre-fabricated wards tailor-made to meet the North's conditions.
They are simple, single-story duplexes. Each can be put up quickly by three or four people, meaning the entire process can be monitored while Linton and other Eugene Bell people are in the country on their bi-annual medical team visits. The wards are already paid for when they are shipped from China, so the money isn't going into the pockets of government officials or funding Kim Jong Un's missile programs.
The idea was to begin putting up 80-100 wards to create large centers in each of North Korea's nine provinces. A pilot project with 10 wards is now operating on the outskirts of Pyongyang, not far from the airport.
Linton said everything was going well until last December.
"Then we ran into this sanctions problem," he said. "It's officially approved. The design is approved. And it's not that we can't send anything in. But these buildings have a metal roof — a panel that has metal in it, aluminum — and that's the issue."
Linton said Eugene Bell has a quarter of a million dollars' worth of them "rotting in monsoon weather" in a dockyard outside of Seoul. He believes that until Washington makes it clear it is not against humanitarian aid, other countries and aid organizations will be reluctant to act — or even approve the shipment of items like Dr. O's GeneXpert cartridges or Eugene Bell's patient wards that are clearly intended for humanitarian use.
As an American, Linton says, he is concerned the U.S. will be held responsible for whatever bad happens with TB in North Korea since no country is as seen as "owning" the sanctions as much as America.
"Unless something is done and done soon, this medical emergency will become known in Korea as the 'Sanctions TB Epidemic,'" he said. "And it will haunt the peninsula for generations."
Talmadge is the AP's Pyongyang bureau chief. Follow him on Instagram and Twitter: @EricTalmadge