While the health of a nation’s leader can have an outsized role on a country, more important to a nation’s strength and wellbeing is the health of the general population. It is from this population that government officials, soldiers, technicians, and farmers are drawn, and if the health of the people is poor, it will be reflected up and down economic, government, and military institutions.
For North Korea, the general state of the healthcare system and the presence of poor health in large segments of society has affected a poorer educational performance, led to higher rates of work-related disability, and has even influenced national security as the military has had to lower recruitment criteria in a reflection of the impacts of long-term malnourishment.
Despite some marginal attempts by Kim Jong-un at improving healthcare (such as the construction of the Pyongyang General Hospital and modernizing the Myohyangsan Medical Equipment Factory) and attempts to improve the food supply, illnesses like tuberculosis still rage through the country and over 42% of the population suffers from undernourishment.
Compounding the problems associated with limited healthcare, food production, and endemic disease has been the arrival of the COVID-19 pandemic and the regime’s response to it. Closing the border has all but ended foreign trade, expelling foreign aid workers has prevented medical and food aid from being distributed, and Kim Jong-un has rejected offers by the international community to provide millions of COVID vaccine doses.
As such, while Kim Jong-un can boast some legitimate accomplishments in other sectors, the efforts to better the health of the people must be seen as a failure.
Health of the Nation
“The State shall protect the people’s lives and improve the working people’s health by consolidating and developing the system of universal free medical service and improving the district doctor system and the system of preventative medicine.” - Article 56 of the Democratic Peoples’ Republic of Korea’s constitution, 2016 version. Emphasis added.
On paper, one might suspect that North Korea has a fairly robust healthcare system. With 133 provincial-level hospitals, 1,608 county-level hospitals, and 6,233 primary care clinics, there are almost 37 doctors per 10,000 people: a ratio on par with Australia. However, despite impressive gains in life expectancy and the proliferation of medical clinics into small villages around the country during the 1960s and 1970s, North Korea currently has some of the worst healthcare infrastructure in the world.
Most clinics are capable of diagnosing basic diseases and setting broken bones, but everything from sterile needles to antibiotics and anesthesia is in short supply. In Kim Jong-un’s North Korea, there still remains no national emergency number (like 119 in South Korea or 911 in the U.S.) and patients must arrange transportation directly with their local hospital. As there are not enough ambulances in the country, private taxis may be required or even asking for transport on a passing tractor.
Despite the constitution guaranteeing free healthcare, people are often required to pay for supplies and medicine prior to receiving any care (including emergency care), and there have been reports of patients needing to provide their own blankets as well as meals for the nursing staff and doctors.
Hospitals capable of providing more complicated services are limited to Pyongyang and provincial capitals, but electricity shortages and shortages of everything from IV bags to modern medical beds hamper even these favored institutions.
The constitution’s guarantee of preventative medicine has likewise gone unfilled under the rule of Kim Jong-un.
An estimated 71,300 North Korean die each year from smoking-related causes. These represent 31% of the total deaths in the country. Although the rate of smoking has gone down, deaths caused by tobacco use are compounded due to a lack of early detection and available treatment options.
To tackle this problem, all three Kim’s have instituted various anti-smoking initiatives, but they have only met with moderate success. Under Kim Jong-un, such initiatives have been seen in 2016 and 2020 which included bans on smoking in certain public buildings.
However, Kim Jong-un continues to smoke in public, undermining efforts to curb smoking among the people.
Tuberculosis isn’t a self-inflicted disease the way lung cancer can be, but it is still an illness that has been controlled in many parts of the world thanks to antibiotics and routine screenings (86% of all new cases can be found in just 30 countries). North Korea has the highest rate of TB among its neighboring countries, and it has been reliant on international aid to keep its spread in check. However, the regime hasn’t always been fully cooperative, and international sanctions have hampered efforts as well.
But while these joint efforts between Pyongyang and NGOs had produced consistent positive results in the decline of TB deaths since 2000, that trend began to reverse in 2016. North Korea’s expulsion of foreign aid workers and border closures in response to COVID-19 also means that the country has been left for over a year with almost no assistance fighting this highly contagious disease.
By December 2020, experts and aid workers who had worked in combating TB in North Korea warned that North Korea would soon run out of the life-saving drug supplies it had acquired in the run-up to the country’s lockdown. One U.S.-based humanitarian official said, "Every untreated TB patient could infect 10 to 15 other people. We could be looking at a much bigger epidemic [in North Korea]”.
Organizations were able to send 918,000 doses of the Bacillus Calmette–Guérin (BCG) vaccine, but the usage rate is over 300,000 doses a year as every newborn is given it. This left North Korea with only a three years’ supply in the best of circumstances.
A further shipment of TB-related treatments was stuck in a Chinese port for months as North Korea worked through their extreme quarantine measures (which extends to both people and products). Lapsed TB treatment plays a role in the development of antibiotic-resistant strains. These ‘super strains’ already account for 21% of new TB cases in North Korea and the country has run out of the drugs needed to fight them.
If Kim Jong-un doesn’t end the lockdowns soon, whatever progress had been made in fighting TB (and drug-resistant TB in particular) could largely be undone. With an estimated 135,000 people currently infected, without treatment, each of those individuals could infect a further 10 to 15 people as stated above.
It must also be said that in the case of North Korea, of five main risk factors, over 65% of TB cases are attributable to undernourishment according to the WHO “Global Tuberculosis Report 2020”; a problem that has only increased due to the extreme nature of the country’s lockdowns.
In terms of being able to provide services and access, North Korea’s healthcare system is deficient in multiple areas.
According to the article “Surgical Diseases in North Korea: An Overview of North Korean Medical Journals” published in the International Journal of Environmental Research and Public Health in 2020, North Korea’s healthcare infrastructure seems to be unable to provide complex surgical procedures like organ transplants.
Based on a review of medical literature from hundreds of DPRK-specific reports, the 2019 study “Systematic review of evidence on public health in the Democratic People’s Republic of Korea” found that cancer screenings appear lacking, particularly for cervical and breast cancers. While both rural and urban women are aware of diseases like cervical cancer, only 6% of women reported having a cervical cytology smear test and 62% of rural women said that travel distances were a barrier to getting screened.
It is this lack of access and loss of faith in the medical system (due to distance, medical costs, and shortages of medicine) that leads many patients to forego visiting hospitals and instead seek medications on the black market and herbal/folk remedies for self-treatment for a wide range of illnesses.
Unfortunately, this has helped to fuel drug addiction in the country as upwards of 61% of patients end up buying opioids on the black market. Without adequate monitoring, both addiction and physical dependence can quickly develop, leading to a host of other problems.
Attempts to limit or ban drug abuse and alcoholism have occurred for decades. Although drug addiction is not as widespread as some suggest, the lack of proper medicine and treatment options requires that people seek help elsewhere. The state doesn’t help matters by being behind the manufacture of drugs like methamphetamine and heroin. In fact, for a time in the 1990s, most of the methamphetamine being abused in northern China came from North Korea.
Despite crackdowns on domestic drug use, abuses of amphetamines and opioid narcotics remain more than a passing fad among the country’s youth. Occasionally reaching epidemic proportions within the northern provinces of the country, the drugs aren’t merely being used for people to get high, but are used to cope with never-ending demands for labor, long working hours, physical exhaustion, and to try to address health problems like chronic pain from injury, disability, and even end-stage cancers.
As briefly mentioned above, compounding the spread of drug use is also its state-sponsored manufacture. With sanctions cutting into the regime’s finances and China taking a harsher view toward drug sellers, domestic drug sellers and criminal gangs have had to find local buyers for their highly potent drugs.
No proper study has been conducted on drug abuse within the country, and the regime often claims it doesn’t even exist, but the reports from defectors are consistent in that drug abuse exists and has reached what could be described as an epidemic at different points since the 1990s, with drug addiction being almost unheard of prior to the famine.
In the field of mental health, competent institutional support for psychiatric problems is almost completely lacking. While some facilities exist, named No. 49 Hospitals, they are described by defectors as little more than prisons for the mentally unwell.
Words like “psychiatrist” and “mental health” are rarely known of by the average person, and the most common way to address mental illnesses of all sorts, it would seem, is for people to either ignore it or try to treat it (as though it were a regular disease) with herbal medicines.
In general, mental health disorders are simply not recognized as such and there is little in the way of research or treatment. Additionally, people can be accused of anti-state activities because they are non-conforming and don’t simply “snap out of it” after being subjected to greater ideological indoctrination. To summarize defector sentiment about the state of mental health in the country, in North Korea, only the mentally sound exist. A sentiment underpinned by the general view that, “psychiatric disorders should not exist in an ideal socialist society.”
Undiagnosed and untreated mental illnesses are also associated with higher rates of suicide, alcohol and drug abuse, and can even express itself through violence in a country where domestic abuse and abuse against women outside the home are already common.
Regarding infant and maternal mortality, North Korea has made continued improvements in infant mortality with the mortality rate per 1,000 live births dropping from 55 deaths per 1,000 in 2000 to just 20 in the year 2020. On the other hand, maternal fatalities are on the rise.
According to the “Report of the detailed findings of the commission of inquiry on human rights in the Democratic People’s Republic of Korea” by the UN Human Rights Council and published in 2014, “almost half of the women surveyed did not see a doctor throughout their pregnancy and almost half delivered their babies at home regardless of whether they were from a major city or village. Women also reported that the death of the mother or baby during or after childbirth was not uncommon. Maternal mortality rates almost doubled in the decade from 1993 to 2003, largely due to inadequacies in emergency obstetric care. The maternal mortality rate in 2010 was estimated to be 81/100,000 live births.”
Maternal mortality has thankfully dropped from 81 deaths down to 66 deaths per 100,000 live births as of 2014, but it is still six times as high as in South Korea, over twice as high as in China, and higher than Cuba’s, another country who has held on to a strict command economy and has been the subject of sanctions for decades.
In particular, the high level of maternal mortality is due to the fact “that many hospitals were unable to provide adequate obstetrical emergency care such as anticonvulsants, antibiotics, and blood products.” Such inadequacies can be seen throughout the whole of North Korea’s medical system.
Although North Korea’s healthcare system has several severe deficiencies, there are areas in which the system is not only competent but has the resources required to provide care such as in basic dental and eye health, and as mentioned above, the system has been able to make strides in infant mortality.
The problem is that these improvements aren’t equally distributed. The most modern equipment and best medicines are first reserved for a handful of elite hospitals that are allowed to work on Kim Jong-un, the rest are distributed throughout Pyongyang. Finally, the main provincial hospitals can expect to receive occasional modernization efforts; although, medicines are often diverted into the black markets or given to the military.
Kim Jong-un has mentioned healthcare in five of his New Year’s speeches, but they were simply token remarks with the exception of 2018. That year he moderately expounded upon the state’s goals saying the state should “apply the people-oriented character in public health service in a thoroughgoing way, and boost the production of medical equipment and appliances and different kinds of medicines.”
Interestingly, “anti-epidemic” work was expressly mentioned in his 2015 speech, but what concrete measures were implemented is hard to say.
Over the last decade, there have been a few large construction projects related to medical infrastructure. One of the earliest was the opening of a new breast cancer research center at the Pyongyang Maternity Hospital in 2012. Although it is reported to be the cutting-edge research and treatment center for breast cancer in the country, as discussed above, travel difficulties remain a major barrier to accessing treatment. Additionally, as entry into Pyongyang itself is restricted, rural women being able to get emergency treatment is even more precarious.
Following that, the nearby Okryu Children's Hospital was opened in 2013. Billed as the best children’s hospital in North Korea, it is where the bulk of pediatric specialists can be found.
North Korea has a high incidence of cataracts and other eye conditions. To combat this, foreign specialists have been allowed to occasionally enter the country and direct mass evaluations of patients and to conduct procedures. However, in 2016 Kim Jong-un order the construction of the Ryugyong General Ophthalmic Hospital. It is the second of two identified eye-specific hospitals in the capital.
In late 2018 Kim Jong-un ordered the modernization of the Myohyangsan Medical Appliances Factory which he found lacking during a visit that October. The factory is responsible for the manufacture of medical beds, dental chairs, and a wide range of other equipment.
A year later in 2019, a medical oxygen plant was constructed. As we have seen in India and elsewhere during the COVID-19 pandemic, having the capacity to domestically produce enough medical oxygen is an essential part of the medical supply chain and is a requirement for the treatment of scores of diseases.
The most recent major medical construction project has been the Pyongyang General Hospital. Slated for completion in October 2020, it sits unopened today. Causes for the delay have been numerous including poorly manufactured electrical insulators and Pyongyang’s inability to import needed equipment. Located in the heart of Pyongyang, right next to the WPK Founding monument, the hospital must be viewed through the lens of being a personal prestige project for Kim Jong-un and the regime; one that is now 15 months overdue.
A kind of long-distance medical system was also introduced in recent years, with a drive to expand the system in 2021, but accessing it still requires patients to travel to their local clinic or hospital, and as personal computers and smartphones are banned for most of the population, patients can’t directly access the system at home. However, according to senior researcher Kim Young Hui of the Korean Peninsula New Economy Center, this remote medicine system has allowed provincial doctors to learn new skills and improve their treatments as they are monitored by doctors at more advanced medical facilities around the country.
Worker health and safety is another key indicator of a government’s commitment to its people, as well as the strength of workers’ rights and labor laws. In a ‘worker’s paradise’ like North Korea, one would expect that labor laws and safety requirements are rigidly adhered to, with tough repercussions for neglectful managers.
However, as there are no independent labor organizations, lobbying or pressure groups, and no independent enforcement agencies, the North Korean state has a monopoly over the entire labor market and set standards as they see fit, and ignore them with impunity.
The constitution guarantees an eight-hour workday and prohibits child labor, but these regulations are routinely ignored. Grade school students, college students, and soldiers alike are all required to work on farms for portions of each year. Teenagers and the adult population are also often called upon to engage in ‘speed campaigns’ of mass, manual labor to build the regime’s latest megaproject. Hundreds of thousands of others are called to duty to perform mass games and serve in military parades.
The labor activities and the training for things like the mass games and parades place a tremendous burden on the body, with injuries being very common and with participants unable to take time off for sickness, to use the bathroom at will, and are rarely provided with enough calories to meet the increased activity level.
A lack of robust occupational safety regulations means that injuries and disabilities in the mining, timber, and construction industries are common. Repetitive stress injuries and the development of chronic conditions within agriculture (which is still largely a feudal activity involving significant human labor) are also routinely found.
All of this means that North Korea has been ranked by the World Health Organization as having the third-worst worker-related death and injury rate in the world.
Based on the “WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury, 2000–2016” report (published in 2021), North Korea had 76.9 work-related deaths per 100,000 workers in 2016. That's an increase from 56.2 in the year 2000. For comparison, in 2016 South Korea had 20.6 work-related deaths per 100,000 workers, China had 39.7, and the United States had 25.7.
Despite alleged worker protections limiting the workday to eight hours, North Korea also had among the worst rates of “stroke attributable to exposure to long working hours.” Long working hours is defined as more than 55 hours a week. North Korea had 28.1 work-related stroke deaths per 100,000 workers in 2016. South Korea and Japan, both countries well-known for their stressful working conditions and long hours had significantly fewer stroke-death rates at 3.9 and 4.9 respectively.
All of this has a significant impact on the North Korean economy, with the country losing an estimated $1.5 billion each year due to work-related injuries, disabilities, and death.
Although North Korea has enacted numerous domestic laws and multi-year plans stated to protect workers and bolster healthcare, and despite voting in favor of multiple international resolutions calling for improved access to trauma medicine, surgical care, and increasing access to basic medicine in rural areas, the lack of implementation means they currently have not made a measurable impact on people’s lives.
North Korea’s Ministry of Public Health announced in their 2016-2020 plan to modernize 200 local hospitals outside of Pyongyang. Yet, the regime has failed to even complete the flagship project of North Korea’s medical sector, the Pyongyang General Hospital, despite it being slated for completion in October 2020 – let alone hundreds of smaller facilities. And a review of satellite imagery indeed shows only a handful of provincial hospitals that have been upgraded.
Also affecting both civilian workers and those in the military is North Korea’s nuclear program. From mining and milling uranium to producing plutonium and testing the finished bombs, the process is fraught with physical dangers and toxic chemicals. In 2019 I wrote two articles detailing the health consequences of Pyongyang’s nuclear program (Part I, Part II).
In short, pollution leaking into the environment from the mining and milling process affects the drinking and irrigation water for thousands downriver. Former workers of the Pakchon Uranium Concentration Plant and from the Yongbyon Scientific Nuclear Research Center have all reported on a number of diseases consistent with both acute and long-term radiation exposure. And, defectors who lived in the areas downwind of the Punggye-ri Underground Nuclear Test Site have reported spikes in illness following the nuclear tests, describing the illness as the “ghost disease” as it comes and goes (following the tests) and causes its victims to become very weak (also consistent with radiation exposure).
The state of health in North Korea is also having substantial impacts on arguably its most important institution, the military.
The health of KPA military personnel received a lot of international attention in 2017 when a soldier defected across the DMZ. He was shot multiple times by fellow DPRK soldiers and required intensive medical care in South Korea. During his treatment, it was revealed that he had large intestinal parasites.
This discovery was not surprising. As many as 47% of North Koreans have helminthiasis, parasitic worm infections. What is surprising is its existence within a soldier who was serving in a relatively elite KPA unit as a frontline soldier of the DMZ.
Food rations in North Korea have long been based on one’s social and political standing, with the military receiving better rations and other supplies as part of the Songun Policy. Thus, one would expect to see fewer infections and other health problems among the military. Yet, this does not seem to be the case ever since the collapse of the economy in the 1990s.
Exposure to these parasites is predominantly due to poor hygiene (only 59% of the population has access to flush toilets), the use of improperly prepared “night soil” (a euphemism for fertilizer made from human waste), and eating food that hasn’t been properly cleaned.
All strata of society, from soldiers to farmers to students, are required to collect night soil and are also required to engage in farming activities. This creates a large level of exposure to parasites and other pathogens.
Chronic parasitic infections are associated with everything from poor cognitive development in children to liver damage. They can also exacerbate malnutrition and make one more susceptible to tuberculosis infections.
Although the levels of malnourishment have fallen since the days of the famine, most soldiers still do not receive their full dietary requirements, leading to soldiers robbing civilians of their food in some instances.
This multigenerational experience of malnutrition has been reflected in the military changing some of its recruitment criteria. Among them, the acceptable shortest height for new recruits was lowered in 2012 to 142 cm (4’ 6”). This change remains today and is not always enforced as the military struggles to maintain recruitment quotas.
Malnourishment and chronic disease can only have one impact – lowering the soldier’s readiness and endurance, regardless of their ideological fervor. Repeated injuries are also common in basic training, while taking part in labor activities, as well as for those who are called up to be part of mass parades. This lack of caring on behalf of the state has been discussed by multiple former KPA defectors, some of whom have taken to YouTube to describe the difficulties associated with military parades.
While the state is ultimately responsible for the general welfare of its people, the inescapable role of international sanctions, levied as a result of North Korea’s nuclear and ballistic missile programs, on the country’s healthcare system cannot be overlooked.
Overbroad sanctions and bureaucracies that move with the speed of pitch have created a complex web of import controls and trade barriers that even make it illegal for North Korea to acquire computer monitors for hospitals and many medicines. Getting specialized equipment into the country is nearly impossible.
In the wake of the COVID-19 pandemic, aid organizations have had to seek exemptions from the United Nations to send even the simplest of medical goods. Gloves, masks, and thermometers are all tightly regulated by international sanctions.
Of course, the regime in Pyongyang has not been helpful in this regard, either. Ignoring their continued development of nuclear bombs which lead to the sanctions being put in place to begin with, Kim Jong-un’s actions to combat COVID-19 can only be seen as criminal.
Kim closed down the country’s borders in January 2020 and put an end to tourism as well. Soon after, foreign diplomats and aid workers were being sent out of the country, group by group. By March 2021, not a single foreign aid worker was left in the country.
This ‘border blockade’ has had multiple effects. It prevents goods and medical supplies from entering the country through legitimate trade and it keeps international groups from being able to bring in and distribute much-needed aid.
The regime’s extreme stance is underpinned by the mistaken belief that the surface of products can be a major source of COVID infections. Everything from visitors to Pyongyang to bus seats has been disinfected more than once, and the government issued shoot-to-kill orders regarding any foreigner who may wash up on their shores (for instance, a wayward fisheries official from South Korea in need of help).
COVID’s threat to North Korea is very real. Although the country is perhaps better equipped than most to enforce local and regional lockdowns to stop any spread of the virus, the country’s medical infrastructure is incapable of dealing with numerous severe cases at once.
To that end, the regime has taken strict measures to quarantine people with COVID-like symptoms and increased legal penalties for those who disobey lockdown orders. North Korea has also tested roughly 50,000 people for COVID-19 and reported zero positive cases. While this has raised a number of doubts (particularly as small outbreaks of COVID-like illnesses have occurred), it does seem that North Korea’s extreme measures have prevented any widespread infection.
However, there have been major consequences to the country’s lockdown measures. Food supplies are running low, people are unable to find daily hygienic items in the marketplace, medications for tuberculosis are running out, and the government can’t import the vast majority of things they need to keep hospitals operating because the border has basically been hermetically sealed.
Although UN medical supplies were sent to North Korea in October 2021, the lack of personnel to distribute the supplies and to independently monitor that distribution means the supplies could easily be diverted elsewhere, as has happened with various other aid and food shipments in the past.
Making matters even worse is Kim Jong-un has the power to end this suffering while also combating the virus. As NK News reported, “North Korea is one of only two countries that has yet to administer any COVID vaccines, despite being promised over 8.12 million doses from COVAX and rejecting another 3 million Sinovac doses.”
Instead, he has taken the opportunities afforded by having a sealed border and almost no foreigners at all in the country for the first time in a generation to crackdown on everything from market activity to going after people wearing skinny jeans (something viewed as being foreign and anti-socialist).
While the war on pants endures, mothers can’t get the help they need during childbirth.
There has been a recent glimmer of hope, however. At least one train has recently been granted permission to enter the country from China to test out North Korea’s new disinfection center at Uiju. If the process goes well, this may open up opportunities for cargo to once again regularly enter the country.
Additionally, the state-party newspaper Rodong Sinmun published on January 10, 2022, that the regime is modifying its anti-epidemic policies to be more “people-oriented”, suggesting that some restrictions may be lightened up. While no specific changes were announced, it is clear that two years of total shutdown have wrecked both the economy and the country’s healthcare system, all without a single COVID case ever (officially) being reported.
The current state of healthcare in North Korea is due to multiple factors. From economic mismanagement to diverting products away from hospitals and clinics to sell for foreign currency to the cumulative effects of years of sanctions. But Kim Jong-un has had a chance to address each one of these major factors and has opted not to.
His anti-pandemic measures have only served to make matters much worse.
The construction and modernization of select medical facilities in the country reflect the regime’s “our way” attitude and are an attempt at self-sufficiency, but the country lacks the indigenous manufacturing capacity to adequately supply itself with even the most basic of supplies. In 2017 the last WHO-certified drug manufacturer in the country was closed down, leaving citizens with only folk remedies and highly dubious “Koryo-medicine cures” made of everything from ginseng to rare earth minerals.
While there have been some statistical improvements, the lack of reliable sources of medicine and equipment, along with constant electricity shortages, has meant that the North Korean healthcare industry is moribund and unable to right itself.
Patients dealing with advanced cancer, mental health problems, or work-related trauma face a medical system that can’t cope due to its inherent structural inefficacies, and that may often actually be detrimental to the patient.
The rapidly declining availability of everything from food to hygienic supplies to antibiotics as a direct result of Pyongyang’s anti-COVID measures does not inspire confidence that the state of North Korean healthcare will improve in the near term, particularly as UN food aid has not been able to enter the country since March 2021 and the regime refuses to accept COVID vaccines that could help them end the lockdown.
And while Kim Jong-un has recently directed that future COVID measures be more tailored and “people-oriented” perhaps hinting at a loosening of some controls, only time will tell if these new policies will have any real impact at all. Currently, all that can be said is that the average North Korean has fewer medical options today than just a few years ago.
~ ~ ~ ~
I have scheduled this project to run through to the end of the year, with a new article coming out roughly every 10 days or so. If you would like to support the project and help me with research costs, please consider supporting AccessDPRK on Patreon. Those supporters donating $15 or more each month will be entitled to a final PDF version of all the articles together that will also have additional information included once the series is finished. They will also receive a Google Earth map related to the events in the series, and can get access to the underlying data behind the supplemental reports.
Supporters at other levels will be sent each new article a day before it’s published and will also receive a mention as seen below.
I would like to thank my current Patreon supporters: Amanda O.,
GreatPoppo, Joel Parish, John Pike, Kbechs87, and Russ Johnson.
--Jacob Bogle, 1/17/2022