North Korea is one of the few countries that has reported “no cases” of COVID-19 infection, and last week leader Kim Jong Un heralded the government’s “shining success” in dealing with the pandemic. The country closed its borders to all foreign visitors in late January, just as it did when faced with the Ebola outbreak in West Africa from 2014 to 2015.
Little is known about how the health care system is run in North Korea, but its apparent ability to escape COVID-19 makes it worth digging deeper into its public health system.
Amnesty International has spoken to two North Korean health care professionals now living and working in South Korea. *Kim is a practitioner of Korean medicine, while *Lee is a pharmacist. Both women believe North Korea has a certain “immunity” to epidemics, but there are also factors which make the country’s health care system particularly vulnerable.
North Korea’s relative “safety” from COVID-19
“As North Korea has been suffering under incessant epidemics, people have built ‘mental immunity’ against them, and are able to deal with them without major fear. This is the same for COVID-19,” Lee said.
“Not that they are immune biologically, but the continuous years of epidemics have made them insensitive.”
She cites outbreaks of scabies and measles in 1989, and the recurrence of cholera, typhoid, paratyphoid and typhus since 1994. After 2000, SARS, Ebola, avian influenza and MERS also threatened North Korea.
However, the fact that no cases of COVID-19 have been reported to the outside world could be connected to surveillance and drastic curbs on freedom of expression at the hands of the authorities.
“North Koreans are well aware that when making contact with family or friends living in South Korea, there is always a chance that they are being wiretapped. So phone calls and letters are usually made under the premise that someone might be listening to or reading their conversations. They will never say a word related to COVID-19, as this can cost their lives,” said Lee.
Ensuring adequate sanitation and affordable care for all
North Korea’s food crisis in the 1990s, known as the Arduous March, caused fundamental changes in its health system.
As Lee explains, “Before the Arduous March, the medical professionals were devoted to their work. Like what the slogans say, ‘A patient’s pain is my pain,’ ‘Treat patients like family.’ But with the economic crisis, the state stopped giving salaries or rations, and survival became the most urgent task. Medical professionals had to get realistic and all those good systems were put aside.”
The result of these changes was effectively a health system based on payments existing alongside the “free” health services. According to Lee, the state opened pharmacies outside hospitals and made people buy drugs with money.
Many people still do not enjoy the right to an adequate standard of living, which covers such areas as adequate food, water, sanitation, housing and health care. But an emerging middle class has started to change the way in which scarce health resources are allocated, and made it even more difficult for poorer communities to access adequate health care.
“Free medical care still exists, nominally, so hospitals don’t charge that much. But some people have recently become willing to pay money for better treatment,” says Kim. “In South Korea, as long as you pay, you get to choose the hospital and the method of treatment. But in the North, you don’t have that choice. ‘You live in district A, so you are to go to hospital B,’ is all there is. Nowadays, people wish to go to the hospital that they choose and see a doctor they want, even at extra cost.
“In the past, doctors only had to look after patients within their assigned area. Regardless of the number of patients, they received a constant salary from the hospital, so there was no need for exceptionalism. Now the patients are bringing money, and this is changing the motivations of health care professionals.”
North Koreans, like everyone, have the right to the highest attainable level of health care. While this does not mean all health care has to be free, the emergence of these unregulated payments does call to question whether health care remains affordable to all or not.
The international community and the right to health in North Korea
Lee and Kim believe that medical training in North Korea is of a high standard and medical professionals are committed to their patients, but one significant bottleneck has been the lack of materials to keep the system running, in part due to sanctions imposed by the international community.
“This humanitarian support comes and goes depending on inter-Korean politics. I personally hope there is steady support from the international community, for example on drugs used to treat tuberculosis, regardless of the political situation,” says Kim. “Much-needed ingredients are entirely procured through imports, but most of them are on the international community and America’s sanction lists.”
Lee agrees: “The facilities stop running because raw materials like petrol for electricity and of ingredients for drug production have been lacking. It’s just a matter of materials. If the supply of these materials were sufficient, I would expect North Korea to be capable of solving public health emergencies smoothly on its own.”
The international community therefore has lessons to learn in ensuring the right to health of individuals in North Korea, in terms of making access to health care more equitable to all people in society.
Economic sanctions must not be applied in a way that would compromise the rights of North Koreans, and arrangements must be put in place to make essential medicines and other health-related items available to people who need them. Restrictions on these goods should never be used as an instrument of political and economic pressure.
International cooperation in nutrition, water and sanitation is also needed to ensure that North Korea is prepared against future epidemics such as COVID-19. Such epidemics may result from diseases related to unclean food and water, and could more readily affect people who already suffer from poor nutrition.
The North Korean government, on the other hand, has the responsibility to ensure that items provided for humanitarian causes are used for their intended purposes free of charge, and not diverted for personal gain. The authorities must fully cooperate with any providers of humanitarian aid, granting them rights of access to all sites where humanitarian operations are taking place, so it can be verified that help is indeed reaching people that are genuinely in need.
*To protect the identities of these individuals, we are only identifying them by their last names.