International Order & Conflict

The State of Sickness

in Program

By Vidal Seegobin – 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 28th 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

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 21st 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.



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