Privation and injustice in North Korea

This article first appeared in The Lancet 353 9151, 6 February 1999

Sir--For the past three years, there has been an unprecedented international aid effort in North Korea. The severe economic crisis together with floods and drought has resulted in an urgent need of food and medical assistance. The government of North Korea, however, continues to adhere to the "Juche" ideology of complete self-sufficiency that governs political policy. Violations of humanitarian principles1 have made conditions impossible for international aid organisations. After months of negotiation with the authorities, Médecins Sans Frontières (MSF) had no alternative but to leave North Korea, as reported in Jonathan Watts' Oct 10 news item.

An estimated 29% of the total food requirement was imported into North Korea in 1998, amounting to about 1 million metric tons, about three-quarters of which came from international food aid organisations. However, the actual number of malnourished people in North Korea has remained the country's best kept secret. Requests by international organisations to carry out a nationwide nutrition survey were met with a minimum of co-operation by the authorities. MSF ran 64 therapeutic feeding centres for around 14,000 children, which represents only 1?5% of the total under-5 population for these counties (provincial districts). However, access to the rest of the population for nutritional surveys and medical assessments was denied by the authorities. Meanwhile, North Korean refugees across the Chinese border spoke of widespread famine, and reported that the authorities had distributed international aid according to social position and party loyalty.

The public health system of North Korea is in disrepair: regular vaccinations stopped in 1994, leaving a whole generation susceptible to preventable diseases; there is a shortage of antibiotics and other medical materials; health centres lack proper heating, electricity, fuel and food; water quality is poor; disinfectants are in short supply. But as with food distribution, the information needed to plan medical programmes is unobtainable, and the distribution of medical materials is restricted to certain districts.

A disturbing example of the control over aid agencies was the discovery by MSF teams of a group of children in an appalling state of malnutrition and disease in Pyongsong hospital. MSF was denied information on the children's background, and not allowed to treat them; their past and future is unknown. What is known is that between 1994 and 1996, the crude mortality rate for children aged younger than 5 years increased from 31 to 58 per 1000 children.

Nevertheless, the government no longer acknowledges a medical emergency. While the health status of the population is seriously threatened, the authorities no longer allow direct humanitarian assistance, but instead are asking aid agencies for assistance in rebuilding the pharmaceutical industry.

A common approach by relief organisations and donors on baseline principles for working in North Korea is needed. Most organisations and donors involved in North Korea supported this idea during the roundtable meeting organised by MSF in Amsterdam in October 21, 1998. The multimillion dollar relief effort funded by governments in the West continues, but without adherence to basic humanitarian principles and proper access to the population, many people of North Korea will continue to suffer.