KOREA: Health care in north Korea

Since its independence, the Democratic People’s Republic of Korea (DPRK) has experienced several stages of development, including post-war reconstruction and industrialisation. The country has achieved many successes, including free education, 100 percent literacy, free medical services and a relatively long life expectancy.

In the early decades of the country’s existence, remarkable economic growth was achieved. Health indicators such as life expectancy and infant and maternal mortality were previously among the best in the region. Unfortunately, from the early 1990s, these indicators were seen to decline, due to successive natural disasters, compounded by the loss of markets, trade, aid and investment following the dissolution of the former Soviet Union and the demise of the European socialist countries, and the intensification of the six-decade long regime of US economic sanctions.

Disaster and recovery

The DPRK is the northern part of a peninsular nation, in which mountains and uplands cover nearly 85 percent of its total area, leaving just 15 percent for cultivable plains and lowlands. In recent years, the country has been affected by unprecedented natural disasters, and is exposed to frequent occurrence of floods, landslides, tidal waves, typhoons, droughts, waves/surges and other types of natural disasters such as wind storms. [1]

Following these disasters, this period saw a rise in malnutrition, communicable diseases and mortality; the US blockade and the collapse of the USSR meant that there was a shortage of necessary drugs, vaccines, medical equipment and surgical supplies, as a result of which aid from international bodies such as the World Health Organisation (WHO) was sought.

However, the infrastructure established during the early years of socialist construction has played an important role in expediting the recent rapid recovery seen in the DPRK’s health services. In 2001, the then director-general of the WHO, Dr Gro Harlem Brundtland, said that the DPRK’s health system was in near collapse. This is in stark contrast to the impression made on the current director-general, Dr Margaret Chan, who visited the country in April 2010 and described the healthcare system as something that most other developing countries would envy. [2]

In particular, Dr Chan highlighted the impressive ratio of doctors to population, the elaborate healthcare infrastructure (centred around the house doctor system), universal coverage, the establishment of telemedicine, 90 percent childhood immunisation, the effective implementation of maternal, newborn and child health interventions, very good directly observed treatment coverage for tuberculosis and success in controlling a recent resurgence of malaria.

Dr Chan was struck by what had been achieved under very difficult conditions. The most up-to-date population statistics for the country include an infant mortality rate of 50.15 deaths per 1,000 live births (51st in world). [3]

Focusing on public health

The DPRK has an extensive and comprehensive healthcare system infrastructure, and all services are free to the people. [4] Under the management of the ministry of public health, the core of public health policy has always been preventive medicine and the promotion of good health.

Policies focusing on preventative medicine were adopted on a wide scale during the period of socialist construction in the 1950s, with a focus on health education, hygiene at home and at work, preventing environmental pollution, immunisation against childhood and communicable diseases, and daily exercise.

Achievements in public health have been attained by developing widespread support for public health, conducting public health work as a mass movement, and avoiding the implementation of policies that may have a negative effect on the health of population. In 2003-2004, 23.3. percent of the national budget was allocated to economic development and 40.5 percent to public health, education, social insurance and social security. [5]

The DPRK’s health infrastructure

The healthcare infrastructure is geographically divided into nine provinces and one municipality of the capital. There are 210 counties, further subdivided in small administrative units called Ri (rural areas) and Dong (urban areas). There is a vast and equitably distributed network of more than 800 general and specialised hospitals at central, provincial and county levels, and about 1,000 hospitals and 6,500 polyclinics at Ri and Dong level, with an estimated staff of around 300,000.

The heart of the infrastructure is the household doctor system. A household doctor is also known as a section or family doctor and is in charge of 150 households. This doctor is qualified to deliver health services (curative, promotive, rehabilitative, and preventative) directly to the households under his charge, but is supported by a referral system to higher levels of care.

The gap in the provision of health services in urban and rural areas, in the plains and mountainous regions has been actively addressed through the appropriate allocation of health workers. This example of centralised planning has resulted in an almost non-existent gap between urban and rural areas in terms of the numbers of household doctors and nurses per household – something almost unheard of in the capitalist world.

Ri hospitals and polyclinics are set up to serve households within a 30-minute walking distance. City, district and county hospitals where specialised care is provided are distributed within one hour travel by car.

The opening of a telemedicine facility in 2008/09 has been a very important development and makes use of information and communication technology to extend access to health care and improve its quality, especially to remote regions. It has also improved training of healthcare staff and allowed better disease surveillance

The DPRK government has given priority to training healthcare staff despite recent adverse economic conditions. There are 100 training institutions for healthcare providers, including medical universities, re-education universities, nursing schools, midwifery schools and schools for dentistry, massage therapy and radiography.

A mixture of western and traditional medical practice has been adopted, but every year, doctors, researchers, post-graduates, and trainees are sent to several countries to be kept abreast of current evidenced-based best practice. In addition, hundreds of healthcare workers go abroad every year to give assistance to other developing countries.

In 2003, the number of doctors in north Korea was 74,597, with 87,330 nurses and 6,084 midwives, equating to 32 doctors, 37 nurses and three midwives per 10,000 population.5

The health of women and children in the DPRK has been systematically improved since the republic was established six decades ago. Family planning services have been available since the mid 1970s. Paediatric and maternity units and specialist hospitals have been reconstructed and enlarged and mobile teams set up for remote areas.

In 2002, 98 percent of pregnant women registered their pregnancies and had deliveries supervised by obstetrically trained healthcare workers. In the past decade, both infant and maternal mortality have shown signs of recovery. Infant mortality which was 21 per 1,000 live births in 2002, [5] had fallen to 19 per 1,000 live births in 2008. [6] Likewise, maternity mortality, which was at 97 per 100,000 births in 2002, [5] had fallen to 77 per 100,000 births in 2008. [6]

The state is currently putting effort into producing essential drugs as well as traditional and preventative medicines. Licensed drugs are distributed through a well-organised system of supply stations set up at central, provincial, city and county levels. In 2003, 100 percent of the urban population and 97.1 percent of the rural population had access to essential drugs within a 5 mile radius. [5]

Challenges

The healthcare system in the DPRK continues to face many challenges. Shortfalls in food (and subsequent chronic malnutrition and malnutrition related diseases), drugs and medical equipment in recent years continue to have repercussions on the health of the population, which are exacerbated by the continuing blockade. Difficulties in accessing fuel also impacts access to higher levels of health services. These are issues highlighted in an extremely critical Amnesty International report on the DPRK’s health system published in 2010.[7]

However, without access to the country, the methodology used in producing this report largely depended on interviewing 40 north Koreans who had settled abroad between 2004-09 and of whom the majority were originally from the extremely poor and remote region of North Hamgyong province.

The Amnesty report pointed the finger of blame at north Korea’s economic model and seemingly provides dramatic support for the western consensus that the DPRK is a ‘failed’ state and, by extension, that a Marxist-Leninist form of government does not work. However, while passing comments were made about the effect of famine, no mention was made of the successive natural disasters the country has been subjected to, the loss of trade and support from the Soviet Union, and the reduction in food aid from south Korea and elsewhere.[8,9] Most glaring was the complete omission of any discussion on the impact that sanctions have had on the country.

The United Nations Committee on Economic, Social and Cultural Rights recognised in 1997 that sanctions “often cause significant disruptions in the distribution of food, pharmaceuticals and sanitation supplies, jeopardise the quality of food and the availability of clean drinking water, severely interfere with the functioning of basic health and educational systems, and undermine the right to work. ”[10]

Former US President George W Bush boasted that north Korea was “the most sanctioned nation in the world”.[11] Sixty years of crippling US sanctions have included limits on the export licensing of food and medicine to the DPRK, a ban on government financing of food and medicine exports, a ban on so-called ‘dual-use’ exports (civilian goods deemed adaptablemilitary purposes) and blocking of any loan or funding through international financial institutions to mention just a few.12

While dual-use sanctions may appear to be targeted, just about any item required for the provision of basic healthcare, sanitation, and educational rights – chlorine, syringes, x-ray equipment, medical isotopes, blood transfusion bags, even graphite for pencils – can be construed to have military uses and therefore banned for export to north Korea.[12]

The implementation of dual-use sanctions played a significant role in destroying the healthcare system in Iraq in the 1990s. Needless to say, failure to discuss the impact of sanctions on the current state of DPRK’s healthcare system is testament to the fact that Amnesty operates within the framework of western propaganda. This, in addition to its shaky methodology, leaves us with a report that has almost no scientific, economic or humanitarian value.

In fact, what is remarkable about the DPRK is not that there are problems, but the incredible advances made in the teeth of a sanctions regime that has been designed to cripple the nation’s healthcare services. The difference between Iraq, where the sanctions regime was successful in destroying an advanced healthcare system, and north Korea, where it has failed to do so, is the socialist system of production and distribution. In north Korea, despite initial reverses, resources have been targeted and all sorts of complex challenges faced down because workers’ well-being, rather than corporate profit, is the main priority of the state.

This is corroborated by eye-witness accounts of the DPRK’s healthcare system, including that of the current director-general of WHO and members of the recent delegation of the CPGB-ML, of whom two were doctors with a total of 16 years of work experience in the UK national health service. These witnesses’ reports reveal a healthcare system that is making active advances, despite the adverse conditions.

Hospitals visited by recent CPGB-ML delegates,13 were impressive in their size, layout, cleanliness and staff commitment to improving services. Although there were shortfalls in cutting-edge medical technology, essential medical equipment such as x-ray machines, ultrasound machines, neonatal incubators, ECG machines and endoscopes were well maintained and clearly available to patients.

In addition to minor procedures, the skill and technology is in place to perform advanced surgery such as cardiac bypasses and valve replacements. The establishment of telemedicine is not only testament to the availability of computing and information technology but also of the commitment shown by the government to improve services further.

Far from crumbling, the health system in the DPRK is making significant achievements and is something that north Koreans are quite rightly proud of.

Notes

1 searo.who.int/Section 3131/Section 1518_6795.html

2 Transcript of press briefing at WHO headquarters, Geneva, 30 April 2010

3 The World Factbook 2010, CIA Publications, cia.gov/library/publications/the-world-factbook/geos/kn.html

4 ‘Emergency and Humanitarian Action Country Report 2008’, EHA in the WHO South-East Asia Region

5 ‘Democratic People’s Republic of Korea: National health system profile’, searo.who.int/LinkFiles/DPR_Korea_CHP-DPRK.pdf

6 ‘2008 census of population of DPRK key findings’, United Nations Statistics Divison, unstats.un.org/unsd/demographic/sources/census/2010_PHC/North_Korea/DPRK%20Final%202008%20Census%20Key%20Findings.doc

7 ‘The crumbling state of healthcare in North Korea’, Amnesty international publications 2010

8 The Los Angeles Times, 25 October 2006

9 The Washington Post, 16 May 2008

10 ’The relationship between economic sanctions and respect for economic, social and cultural rights’, United Nations Economic and Social Council, 12 December 1997

11 ‘Sanctions of mass destruction’ by John Mueller and Karl Mueller, Foreign Affairs, Volume 78, Number 3, May 1999

12 gowans.wordpress.com/2010/07/20/amnesty-international-botches-blame-for-north-korea%E2%80%99s-crumbling-healthcare/

12 CPGB-ML delegation to DPRK, September 2010, youtube.com/user/ProletarianCPGBML