The State of Sickness

October 28, 2010

Analysis of health systems and outcomes, to date, has not been a part of traditional analysis of North Korea. Nevertheless, an examination of the health situation in the "hermit kingdom" paints a very stark picture that casts doubt on the long-term sustainability of the current regime.

The September 28^th Worker's Party Meeting  recognized Kim Jong-un, the youngest son of the current leader of North Korea and newly minted four-star general, as the anointed leader to a new generation of governing elite. Unquestionably, however, any North Korean leader will face nearly impossible challenges in preventing deteriorating health outcomes and inadequate health systems from eroding the party's ability to maintain 'Juche,' the North Korean ideology of self-sufficiency.

Data from the secretive communist country is difficult to come by.  But health information from UNICEF and the World Food Program, which operate in North Korea, corroborate suspicions that the average North Korean suffers from severe food insecurity and poor health.   An estimated 45% of children born in North Korea suffer from stunting, or markedly low height-for-age, as a result of chronic malnutrition.   Such malnutrition has devastating long-term impacts on populations because it permanently impairs physical and cognitive development, a frightful and protracted destruction of an entire generation through hunger.   Interviews with migrant North Koreans, described by Dr. Gilbert Burnham in a recent presentation at the US Institute for Peace, indicate that more than 80% of households have had at least one member in the hospital over the last year. The average hospital stay was recorded at an astonishing 30 days and nearly 90% of costs were out of pocket. Moreover, internal and external migration of individuals with multi-drug resistant tuberculosis is a daily reality and a troubling manifestation of the country's declining life expectancy. 

According to public health professionals from Johns Hopkins who have visited Pyongyang, years of isolation have transformed a once robust health infrastructure into a network of empty buildings with unused diagnostic laboratories and operating rooms. Until the 1960s, North Korea's health systems outpaced those of its neighbor to the south in ability to deliver better health outcomes, even if service delivery was inefficient. With an organizational structure similar to other collectivist countries like Vietnam, polyclinics at the local level were designed to provide primary health services, referring more complex cases to provincial or eventually national hospitals. Now, knowing that these clinics most likely lack basic supplies to conduct even rudimentary tests, patients bypass the local level and flood equally constrained provincial level facilities - if they seek health care at all. Patients often have to bribe doctors with gifts for services; overall out-of-pocket costs exceed the average $US 43 dollars a month a North Korean household earns.

North Koreans have adopted multiple coping mechanisms to survive despite, rather than by, the rules and spirit of a self-sufficient communist society.  External food and health assistance is often diverted into the gray market kiosks where most North Koreans buy and sell everything from vegetables to medicine.  Factories often maintain their own gardens as a way of supplementing food for workers. The scramble is so desperate that remittances from families abroad not only entice law enforcement to shake down families, but to compete for their marks with other enforcement officials. Together, the interaction of poor health, failing delivery systems and predatory officials represent short-term, temporary fixes that sound less and less like a cohesive society in service of a beloved leader.

The personality cult established by Kim Il-Sung tends to make traditional models of political and economic analysis inadequate.  Nevertheless, stable economies from agrarian to knowledge based rely on human capital. Through examination of health metrics and health systems, a more comprehensive picture of life for North Koreans and what it means for the country's future takes shape. Leaving aside the question of whether deplorable and worsening living conditions faced by average North Koreans could any further delegitimize the government, what becomes clear is that the Party can only exhaust and tax its human resources so far before the North Korean government will have no choice but reform or collapse. After all, what is a worker's party when the people are too infirm to work?

Traditionally, we tend to imagine rebuilding a country's health infrastructure from scratch: constructing hospitals and laboratories, training doctors and nurses, and procuring equipment.  But there are already significant assets in North Korea.  With an open border, North Korean access to medical supplies and knowledge would no longer be the primary limitation to better services. Idle health clinics could ramp up relatively quickly because the hard infrastructure, systems and people are already there. And while it is true that no amount of aid or trade will overcome a generation of physical and cognitive impairment from malnourishment, the absorptive capacity of North Korea's health system is higher than many other donor-assisted countries.  Additionally, health diplomacy and the provision of basic health assistance to perennially underserved populations by South Korean and multilateral organizations would not only be preferable to over reliance on food assistance that is often captured by the government before it reaches the people, it could make great strides in dismantling generations of propaganda against and isolation from the rest of the world. In what may be one the great ironies of 21^st century international relations, public health demands could lead to an end and a beginning for the hermit kingdom.

Photo Credit: "Girl Watches Out of the Classroom Window" Michael Huggins/ World Food Program. Democratic People's Republic of Korea, October 2006.

http://www.wfp.org/photos/school-feeding-girl