At  a time when questions are being raised in both South Korea and the international community about the seriousness of food conditions in North Korea, a US philanthropist who recently returned from the isolated country warned of a greater danger closing in: a murderous epidemic.

Stephen Linton of the Eugene Bell Foundation, which provides humanitarian assistance to North Korea, is widely considered in Seoul to be the American citizen with the widest access to rural areas of the isolated country, to which he has been traveling for two decades.

Linton, who returned from his latest trip to North Korea earlier this month , estimated that there are some 130,000 tuberculosis patients being treated in the country at present. But if essential drugs are not pre-ordered on the international market in the next three months, the country’s supply will run out by next June.

“Right now,” Linton told a small group of foreign reporters in Seoul this morning, “we are trying to prevent a disaster.”

The prevention of that disaster bestrides a deeply troubling moral fault line – one that separates the nature of the Kim family regime in the remote country from whatever responsibility global society has, or feels, for ordinary North Koreans.

The famine question

Earlier this month, United Nations agencies warned that 10 million people – almost half North Korea’s 24 million – face food shortages due to dry spells, heatwaves and flooding.

The UN Food and Agriculture Organization and the World Food Program concluded that reduced harvests had left North Korea with a 1.36 metric ton food deficit, the worst shortfall since 2008-2009. State food rations have been slashed to their lowest-ever levels, requiring many families to cut both nutritional intake and nutritional diversity.

Also in May, North Korea state media said the nation was suffering its worst drought in decades.

However, some question these claims.

Last week, prominent American conservative Gordon Chang, citing right-wing North Korea watchers in Seoul, charged Pyongyang with failing to open its rice-storage warehouses, notably those used by the military. This, he suggested, proved that North Korea is not – or at least not yet – facing a dire food shortage.

Chang also questioned the veracity of the UN report, given UN staff’s reduced access to parts of the country and reliance upon North Korean data.

Linton – while claiming no expertise in famine relief and warning against analyses based upon “looking through a limousine window” – nevertheless offered some observations.

He noted that the current situation inside North Korea is “a lot better than it was in the 1990s” when, during the so-called “Arduous March,” hundreds of thousands, possibly millions, perished in famines. North Koreans “are inured to humanitarian disasters and are much more proactive than they were before,” he said.

Still, the mountainous, heavily sanctioned country’s food supply is precarious. Given the timing of harvests, May and June are customarily the worst months.

“Every spring, before the potatoes come in at the end of June, there is a food shortage of some kind,” Linton said. “As usual, there are indications that the food supply is bad now. Is it worse than before? I don’t know. It’s a chronic situation.”

Where Linton sees true peril is in tuberculosis, a disease exacerbated by malnutrition that weakens immune systems.

A deadly and difficult disease

He noted that tuberculosis, while as deadly as ebola, is not as dramatic: It kills over years not days, so does not hit the global public panic button. Moreover, TB is highly communicable, with one patient likely infecting 10-15 other persons. Compounding the disease’s already problematic nature is that certain strains are resistant  to certain medications.

Due to these complexities, treatment is not straightforward.

First there needs to be screening to ensure that patients are prescribed appropriate medication. The Eugene Bell Foundation has donated five screening units, which Linton said are now efficiently run by local staff in Pyongyang. The foundation also travels the countryside, running mobile screening operations. Even so, Linton warned, North Korea has only 10% of the screening facilities it needs.

Once a patient has been screened, via spit tests, appropriate medication needs to be prescribed, in specific doses and timings. These medications are varied.

The costs for drug-resistant strains is “over a hundred times more than for regular medication,” Linton said, but there is no effective treatment other than correct medication, correctly administered. “The only way to treat a disease that is an epidemic is to have so much medication available that it is never an economic issue,” he said. “If that happens, market forces get involved.”

That mean patients themselves acquire commercially available medications – such as can be purchased in China –  that are inappropriate for their personal conditions, and/or do not take the correct dosages. This exacerbates drug resistance.

In the background of this fraught treatment environment, a deadly clock ticks.

Disaster countdown

North Korea’s current stock of TB medications will, unless replenished, run out by next June, Linton said. Supplies need to be ordered, nine months in advance, from the Europe-based Global Drug Facility, which makes a product that controls four strains of TB in one medication.

That leaves just three months for the medication to be pre-ordered.

If medications are not ordered soon, “there will be a vacuum where North Korea’s TB system runs out of  TB medicine,” he said. “Before that happens, they are probably going to start hoarding it and trying to decide who gets it and who does not, which is counterproductive in a contagious disease situation.”

A major stumbling block faces the placement of the necessary order.

For eight years, the major donor of TB drugs to North Korea was the Global Fund to Fight AIDS, TB and Malaria, which operated via UNICEF and the WHO. But last February, it ceased operations in North Korea citing – vaguely – the difficulties it faced operating in the country.

Linton expressed surprise at the decision, citing the cooperation his organization has received from North Korean authorities. He asserted that while there are often political objections to development aid, such obstacles should not hinder humanitarian aid, and the two forms of aid should not be lumped together.

Late last year, “after a year of struggle” in Linton’s words, the Eugene Bell Foundation was one of a handful of NGOs that were quietly permitted, by the UN Security Council Sanctions Committee, to take essential aid into North Korea – as reported by Asia Times at the time.

However, that aid is far from enough.

The Pyongyang problem

The Eugene Bell Foundation declined to comment on what prevents Pyongyang, which recently conducted a series of expensive missile tests, from pre-ordering and purchasing TB medications itself.

“Historical precedents show that North Korea has put a low priority on purchasing much-needed medicines and supplies for its domestic health care system,” Chad O’Carroll of Korea Risk Group told Asia Times. “That being said, if it did want to buy medications now, it would probably find it difficult due to the global sanctions regime and its prior status.”

North Korea, which is largely fire-walled from the global financial system, could face extraordinary difficulties physically mobilizing funds to buy medication, O’Carroll explained, while global firms and middle men would be reluctant to deal with Pyongyang.

This indicates that the regime will rely on the goodwill of overseas parties. “Pyongyang has other concerns,” he said.  “They will likely leave this problem to foreigners to try and fix.”

These troubling ethical issues may explain why Seoul has been agonizing over the dispatch of $8 million in humanitarian aid to North Korea.

Last week, the government announced that it was discussing the matter with international organizations while sounding out the public. “On the matter of direct aid, we will consider the matter while sufficiently garnering the opinions of our citizens,” a Unification  Ministry spokesperson said.

Yet Linton warned against politicizing an epidemic.

“The problem is everybody is so used to seeing everything about North Korea through a political lens,”  he insisted. “This has to be apolitical.”