As this paper goes to press, relations on the Korean Peninsula are at their tensest level in more than 20 years. Since 2006, when the Democratic People’s Republic of Korea (DPRK) announced that it had restarted its nuclear facilities, the government has challenged international nonproliferation treaties on several occasions. Domestic plans for transfer of leadership to Kim Jong-un bring new complexities to government relations with the outside world. Following military incidents in 2010 along the long-disputed Northern Limit Line in the Yellow Sea, China, which is North Korea’s most important ally, the United States, South Korea, and other governments have been working intensively behind the scenes to keep tensions in check.

The DPRK is a foreign policy conundrum. While the regime’s nuclear ambitions remain at the forefront of international security concerns, the world is painfully aware that this isolated and enigmatic country of 24 million people is also plagued by crippling energy, food, and medical shortages. Since the famines of the 1990s, rates of tuberculosis (TB), a disease that exploits malnutrition and other conditions that compromise natural immunity, have risen dramatically and are now among the highest in the world outside of sub-Saharan Africa, including more than triple the rates in China and South Korea. From 1995 to 2003, the U.S. government provided more than a billion dollars in food, energy, and medical assistance to North Korea. Absent an impact of humanitarian efforts on broader diplomatic opportunities, international humanitarian contributions have fallen off dramatically in recent years even as the North Korean economy continues to struggle. In the decade since the breakdown of the Agreed Framework, it is increasingly apparent that policies tying economic aid to nuclear disarmament are not working.

In this paper, we describe our experience working with the civilian DPRK Ministry of Public Health (MoPH) to develop the country’s first modern TB laboratory. Begun in 2008, this unique collaboration of U.S.-based voluntary interests, including a major medical institution, a humanitarian nongovernmental organization (NGO), and a nonprofit sponsor, has achieved a critical public health objective during a period otherwise marked by profound deterioration of relations with the United States and its allies in East Asia. Because coordinated global efforts are needed to control TB in the antibiotic era, we argue such engagements can encourage broader assimilation within the international health community.