If North Korea can make fake Viagra for export, why can’t it make TB drugs for sick North Koreans?

Since the collapse of North Korea’s nominally free public health system, contagious diseases have spread widely, but only a lucky few North Koreans have been able to find medicine and medical care. Most of its people get by on whatever health care they can afford and whatever drugs they can find. A lucky few use retired doctors or doctors who moonlight after regular working hours. Some pay steep bribes to get access to care and medicine in state hospitals and clinics. Some buy medicine from market vendors, which may or may not be fake. The least fortunate rely on unlicensed healers, soothe their pain with methamphetamine or opium, or simply go without.

As the Washington Post recently discovered, however, if you’re a foreigner with hard currency, it’s not at all hard to buy medicine in Pyongyang. In May, a Post reporter visited the North Korean capital, possibly for the recent Workers’ Party congress, and “bought a box of the North ­Korean-produced medicine to treat erectile dysfunction.” He then “sent it to a Pfizer lab in Massachusetts to be tested.”

Surprisingly, each dose of Neo-Viagra — brown granules in a vial that looks like traditional Korean medicine — turned out to contain 50 milligrams of sildenafil, the active ingredient in Viagra. The little blue genuine Viagra pills come in 50- and 100-milligram doses.

“Lab analysis of the product known as ‘Neo-Viagra’ . . . did detect the presence of sildenafil,” said Yasar Yaman, Asia-Pacific director for Pfizer’s global security team. “Sildenafil is the active ingredient in Viagra, however this is a different formulation to the sildenafil found in authentic Pfizer tablets.” [Washington Post, Anna Fifield]

This finding should not have been too “surprising,” given longstanding rumors that North Korea sells many counterfeit products, including Viagra, as Fifield notes later. This was my favorite line in the story, by the way:

Pfizer couldn’t say whether the medicine would actually work or was safe because it had not conducted any clinical trials, and the reporter was not successful in convincing any male acquaintances to try it.

Pfizer told the Post that it was “‘currently reviewing’ whether to take any action against the North Korean manufacturers for patent or copyright infringement.” Pfizer’s lawyers will find that it is possible to sue a foreign government that engages in “commercial activity;” but historically, the plaintiffs who’ve obtained large civil judgments against the North Korean government for its terrorist acts have found it difficult to find North Korean assets to attach. A more promising strategy may be to identify and sue the Chinese and Russian companies that are selling the North Korean viagra and try to attach their assets.

Websites based in China and Russia have been selling Kumdang; Neo-Viagra; Tetrodocain, which purports to treat an array of diseases including tuberculosis and HIV; and Chonghwal, which is said to do the same job as Viagra. [Washington Post, Anna Fifield]

There is, needless to say, no independent scientific evidence for the effectiveness of North Korea’s cure for HIV. There is evidence that other North Korean “medicine” is toxic or harmful. An investigation by Radio Free Asia found that North Korean doctors in Tanzania have prescribed “medications containing high percentages of lethal heavy metals to patients.” According to an anonymously sourced story published by Radio Free Asia, North Korea has at least two factories that make supplements to enhance the performance of athletes, and it reports that those drugs are in high demand among the elites in Pyongyang for “recreational” use. RFA did not test a sample, but South Korea’s Ministry for Food and Drug Safety did analyze samples of North Korean-made supplements for sale in Asian countries and found that some “exceeded the permitted levels of hazardous heavy metal substances,” including mercury, arsenic, and lead. Another, called Keum Dang No. 2, contained “[n]arcotic components.” Vietnamese authorities suspended sale of the supplements following the reports.

Much later in her story, Fifield alludes in passing to the greater harm done to the North Korean people.

Indeed, North Korea’s pharmaceutical factories have largely ground to a halt along with the rest of the industrial sector, and many pharmaceutical products are imported from China to be sold in the markets. Medicines for chronic outbreaks are donated by humanitarian organizations, such as the drugs to treat multi-drug resistant tuberculosis that are imported from South Korea.

I don’t want to move off this point just yet. Instead, I want to turn to another story by the same reporter from last March. Its tone is much darker than the quirky tale of the fake-but-effective Viagra and the plucky little regime that defies the world to sell boner pills to middle-aged guys with more money and libido than sense.

The lives of more than 1,500 North Korean tuberculosis patients are at risk, an American-run humanitarian foundation said Wednesday, because tough new sanctions are stopping medicine from getting to sick people.

After the United Nations imposed multilateral sanctions this month as punishment for North Korea’s recent nuclear test and missile launch, South Korea this week imposed direct sanctions of its own. But unlike the unilateral U.S. sanctions recently passed by Congress, the South Korean measures do not make a general exception for humanitarian aid.

That has hamstrung the ­Eugene Bell Foundation, which treats people with multi-drug-resistant tuberculosis inside North Korea but cannot get the export licenses it needs to ship medicine from the South to its treatment facilities in the North.

“Unless something is done quickly, our patients will fail treatment and die,” said Stephen W. Linton, chairman of the foundation. “Short of all-out war, I cannot imagine a greater tragedy for the Korean people.” [Washington Post, Anna Fifield, March 9, 2016]

Let’s stipulate that when South Korea temporarily blocked that shipment of tuberculosis drugs, it made a misstep. U.N. sanctions emphasize that sanctions should be administered to avoid adverse impact on humanitarian aid programs. Blocking humanitarian aid shipments does nothing to help enforce sanctions, and only plays into the hands of dishonest or ill-informed criticisms that sanctions only hurt the North Korean people. The Post’s headline for that story played into that narrative perfectly. It read, “North Korean tuberculosis patients at risk as sanctions hamper medicine shipments.” (Emphasis mine.)

The best I can say for this headline — reporters don’t necessarily write their own headlines — is that it isn’t entirely false. As narrowly applied to South Korea’s unilateral sanctions, it was true at that time. It’s also true that U.N. and U.S. sanctions have had indirect effects on humanitarian aid, but only for reasons that the North Korean government itself could easily avoid. Because North Korea co-mingles its proliferation-related transactions with the transactions it uses for other, non-sanctioned purposes, aid groups report that banks have also hesitated to process transactions related to aid shipments, too. That’s unfortunate.

It’s also unfortunate that the aid groups that operate in North Korea under the watchful eyes of state minders — and who must keep the recent examples of Regina Feindt and Sandra Suh in mind — use those delays as excuses to blame sanctions for the hardships of the North Korean people. What makes that criticism dishonest — even unethical — is those same groups’ consistent refusal to hold the North Korean government responsible for the deliberate policies and priorities that impoverish the North Korean people to begin with. You will often hear NGOs criticize U.S. or U.N. sanctions for hampering shipments of TB drugs, but you will never hear these same NGOs call on Kim Jong-un to produce TB drugs instead of Viagra, supplements, methamphetamine (see also), or narcotics to sell for a profit.

The press also bears its share of blame for failing to raise legitimate questions about that narrative. One of those questions is why a regime that can afford yachts, jewelry, and luxury sedans can’t afford to import medicine. Another is why a regime that can make Viagra to raise cash can’t make TB drugs for its sick citizens. In that light, headlines that blame sanctions for denying the North Korean people medicine — medicine their own government has the means to make and provide, but has chosen not to — are misleading at best. 

I’m not a pharmaceutical expert, so the assumption I’m making is that it’s no more difficult to make anti-TB drugs than it is to make Viagra. I invite readers to question that assumption. What’s clear is that Pyongyang has the means to produce advanced pharmaceuticals when it smells a cash profit. Unfortunately, the welfare of the North Korean people is a lower priority than whatever priorities Kim Jong-un has in mind for the revenue he earns by exporting his country’s health care workers and drugs for sale to foreign buyers. 

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Prisoners of the People: N. Korea’s guerrilla society has political implications (updated)

Over the last year, I’ve become convinced that if technology can break the electronic barriers between North Korea and the Outer Earth, it would be possible to keep the broken promises of the Sunshine Policy by bypassing Pyongyang and engaging directly with the North Korean people. Governments, churches, and NGOs could harness markets, smuggling networks, and private agriculture to help North Koreans feed the hungry, heal the sick, share information and ideas, begin to rebuild their broken civil society, and eventually, negotiate with the state for what is rightly theirs. 

A new civil society independent of the state, and increasingly at odds with the state’s political objectives, would co-opt, corrupt, and supplant the state’s control over the population, particularly if the state is demoralized, corrupt, weakened by sanctions, and unable to pay its security forces. If it all seems impossible, consider two cases in which that trend is well advanced in North Korean society now — financial services and health care. 

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Reuters writes that a guerrilla banking system has sprung up inside North Korea. For the most part, Reuters describes a system in which merchants who profit from state-sanctioned trade lend money to state-owned enterprises, mostly for the state’s benefit. This amounts to crony capitalism; it’s the least interesting of the three types of financial services that emerged in North Korea over the last decade.

The second type of service is loan sharking by the well-connected against the structurally impoverished. In some cases, the desperately poor agree to pay usurious interest rates to borrow food. You can imagine how some of these stories end. A month ago, for example, the Daily NK reported that a well-liked young woman stabbed a loan shark to death for pressuring her to make payments she couldn’t afford, and “will probably be executed via other means as soon as the court proceedings come to a close, perhaps with an instrument such as a rubber baton.”

The third, and least exploitative system is the one North Korean refugees currently use to send remittances to their families back home, although that system is risky for the smugglers and the recipients, who become vulnerable to extortion by the police. It’s also expensive — the refugees pay steep commissions from their hard-earned pay to send these pittances home.

The situation that has developed clearly fills a need in the marketplace, but ethically, it’s obviously far from ideal. If the technology existed to set up secure online banking through messenger apps, it would be possible to send remittances and humanitarian aid from South to North Korea with a minimum of risk and cost, and to extend microcredit to the poor in more regulated and ethical ways.

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But the report that fascinates me the most is one I read over the weekend — Eun Jeong Soh’s paper, “The Emergence of an Informal Health-Care Sector in North Korea,” published in the Asia-Pacific Journal, and based on extensive interviews with refugees, including health care workers, from North Korea. One of the more ambitious things I’ve advocated is supplementing, and largely replacing, North Korea’s broken public health system with a guerrilla health care system for those who can’t afford the bribes and fees that are a de facto cost of North Korea’s “free” health care. Soh’s paper suggests the extent to which something like that has already begun to happen spontaneously. Like most of North Koreans’ adaptations to the failure of the state, this new system was illegal, which meant that it necessarily relied on informal networks and a high degree of mutual trust.

At first, many of these home healers were quacks and unqualified traditional healers. Over time, more retired and off-duty doctors began moonlighting for trusted patients. The services they provide have improved in quality as the state hospitals increasingly do little more than use their equipment to diagnose ailments. Today, those who can afford it prefer to use private doctors, who refer patients to back-alley pharmacists to supply medicines. So well developed are the markets’ smuggling networks today that the quality and authenticity of the medicines sold by back-alley pharmacists is now as great a concern as their availability.

Up to this point, Soh’s paper mostly adds richness of detail, anecdote, evidence, and analysis to trends North Korea watchers already knew of, or might have reasonably extrapolated to the state of affairs she describes.

But the state still hovers over all of this. How do informal networks grow despite a state that wants to stamp them out, isolate citizens from each other, and maintain its monopoly over essential services? One way is for private doctors to form protective relationships with the security forces — “she provides him with free medical assistance and he protects her from any official repercussions that her activities might incur.” But Soh’s subjects also report that the state also holds back, fearing that if it cracks down, there will be discontent and unrest. It’s a long quote, but worth reading.

In describing this informal hoarding system, she conveyed the sense of injustice she feels about what the system has become, even though, in times of personal need, she had herself acquired drugs directly from the hospital.

How is such shared moral outrage expressed and communicated to the bureaucrats charged with enforcing the regulations? Dissatisfaction can be expressed verbally as a way of confronting local officials directly. Interviewees argued that in order to survive in North Korea, one often has to take a firm line and defend one’s position logically in order to persuade officials of the merits of one’s case. While this might seem surprising given the state’s tight control over its citizens, the expression of complaints to local officials is facilitated by preexisting relationships between officials and complainants formed through family networks, neighborhood relations, friendships, a shared history as classmates, and so forth. Social relations in small regional cities in North Korea are close, shaped by cultural traditions, socialism, and communalism, and reinforced by the coping and survival strategies developed to weather times of hardship.

However, given the nature of a regime that does not accommodate dissent, the expression of dissatisfaction generally takes non-verbal forms. One term that cropped up frequently was “disaffection” (panbal). In the narratives recorded in this study, panbal refers to feelings as well as expressions of disaffection against the authorities (normally local officials charged with regulating anti-socialist activities), as well as with life in general. Although the authorities are well aware of such disaffection in the populace, Ms Hahn expressed her opinion that in reality the government lacked the power to impose its own regulations: “If the authorities regulate even those activities, there would be too much disruption” (Interview, S. Hahn, October 26, 2013). According to a former police officer, “a police officer will be unpopular if he takes unnecessary enforcement action” (Interview, M. Park, November 18, 2013). If complaints against local officials accumulate, they will damage their reputation with residents. In E. P. Thompson’s words, referring to the 18th-century English crowd, “the authorities were, in some measure, the prisoners of the people” (Thompson 1971, 88).

From the point of view of local officials, the existence of these informal coping networks and strategies are to be applauded, as alternative ways of providing health care may have the effect of allaying complaints by residents. Local officials also have private incentives to turn a blind eye to such informal activities. Normally, these private practices operate with the help of local police who accept bribes from practitioners. More importantly, police officers also draw on the services and expertise of informal health-care workers for their own families’ survival and wellbeing. As a result, local officials and residents have come to share similar views on these extra-judicial activities. Thus the convergence of preferences among providers, consumers, and regulators has contributed to the emergence of an active and evolving informal health-care sector in North Korea.

So it was that North Koreans who harbored no explicit political motives learned to resist and conspire against the state, and to defeat the prisoners’ dilemma it imposed on them.

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North Korean parents are catching “private education fever” as more and more of them are risking arrest as they venture outside the secretive state’s educational system in the hope that a private tutor will help their children get into a top university.

“The goal of these parents is to send their children overseas or to the best colleges in Pyongyang,” a North Korean who recently visited China told RFA’s Korea Service. “There have been slogans going around saying: ‘Let’s send them overseas!’ or ‘Let’s send them to Pyongyang!’”

In North Korea, where the state tightly controls education, hiring a private tutor is illegal, but more and more parents are taking the risk and paying the price

“Subjects like mathematics, physics or any other of the core studies cost 100 [Chinese] yuan (U.S. $15.00) per month in Pyongyang, whereas subjects that need specialized skills like computer programming cost between 200-500 yuan (U.S. $30-$75) per month,” said the source, who talked to RFA on condition of anonymity.

The fever doesn’t end with academics as so-called “extreme” North Korean parents, who want to raise “civilized” children, pay more so their kids can learn to play at least one instrument and take part in athletics, explained the source.

“Children of the privileged class in Pyongyang spend about 1000 yuan (U.S. $150) monthly for private education expenses,” the source said. [RFA]

To do this, the parents have to pay bribes to get their kids excused from regular school or labor mobilizations. The tutors are also at risk of arrest, so many are well-connected people who are relatively untouchable.

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A guerrilla health care system for North Korea’s poor

Gullible leftists and U.N. nincompoops who take North Korea’s claims of socialist equality at face value love to bleat about the wonders of its free universal health care, but those bleats have little basis in reality. A 2010 study by Amnesty International found that Pyongyang provides less for the care of its non-elite citizens per capita than almost any other nation on earth:

The North Korean government has failed to adequately address the country’s ongoing food shortages since the 1990s. This failure has led to the current critical situation in which the population faces severe health problems associated with malnutrition. Compounding these problems, North Korea’s government has failed to provide adequate resources for its health care system, which as a result is wholly unable to cope with the growing number of illnesses and diseases of a population weakened by hunger.
According to the WHO, North Korea spent less than US $1 per person in 2006. [….]
In fact, North Korea had one of the lowest recorded per capita total expenditure on health in 2006 of any country in the world.105 The state’s paltry expenditure on health, in spite of the urgent need for medical training, access to medicines and public health education, violates North Korea’s obligation to provide for the basic health of its population. [Amnesty International]

Outside Pyongyang, clinics lack basic medicines and supplies, and care is available only to those who pay for it with cigarettes, alcohol, or cash. Doctors often receive little or no pay, so they demand payment from their impoverished patients instead. According to one refugee interviewed by Amnesty:

“People in North Korea don’t bother going to the hospital if they don’t have money because everyone knows that you have to pay for service and treatment. If you don’t have money, you die. People without money just have to hope that they don’t get sick or can get better on their own. Doctors will not treat patients without compensation, especially for surgery. Nothing is free anymore.” [Amnesty]

Sick people who can’t get medicine are forced to rely on traditional medicine, or use methamphetamine or heroin as substitutes. Women, including those whose circumstances have forced them into prostitution, take heroin in the false hope that it’s a contraceptive. Communicable diseases (1234) spread widely. Tuberculosis is rife; even in the army, it goes untreated until the soldier is sent home to die. Medicines donated by aid agencies show up for sale in markets. While Pyongyang exports doctors to Africa and the Middle East, inside North Korea, the demand for medical services so exceeds the supply that some sick people seek out unqualified healers instead. The actual doctors who remain have gone into business for profit, and not unreasonably; after all, doctors need to eat, too:

“More recently, there have been doctors who diagnose patients and others who fill in prescriptions. The medicine is then sold to patients, so trade in this field is growing.”

This trend was corroborated by two additional sources in North Pyongan Province.

The most crucial element in medical treatment is an accurate diagnosis, which is why so many people in the past had died from cirrhosis and ascites. However, recently those numbers have been falling thanks to a greater wealth of medical experts offering services through the back door, according to the source. [Daily NK]

Some of these providers are retired doctors from state hospitals. Others are unlicensed healers.

“The free medical system has been lost on people, leaving them without any treatment unless they pay up bribes at state hospitals. Struggling to even receive a proper diagnosis, people have been seeking out these doctors,” the source said. This has led to the build-up of a much more structured, systematic, and specialized market for health care.

Some Korean medicine doctors who have earned great reputations see patients lining up in front of their doors from the crack of dawn. They charge around 10 USD for a diagnosis, and the cost for prescriptions varies widely depending on the medicine required for treatment, according to the source. [Daily NK]

The regime periodically cracks down on this trade, but now that even high officials have begun relying on free market medical care, they can’t completely suppress it, either.

This evidence not only refutes the unserious narrative of North Korea as a model for public health services, it also raises more serious questions of whether foreign aid programs that channel their funds, supplies, and medicines through the state work. The beneficial impact of these programs is probably greater than zero, but they certainly haven’t been a broad solution North Korea’s public health crisis. It suggests that donors need a better use for their scarce aid resources than pouring them into the black hole of Pyongyang.

As is the case with North Korea’s food crisis, the market-based solutions that North Koreans have found are both a symptom of the problem and a potential solution to it. One wonders: if the regime allocates medical services based on the patient’s political caste, and if this has, de facto, further reallocated services based on one’s economic class, why can’t NGOs find ways to pay North Korean doctors to treat the patients whose need is greatest — starting with North Korea’s orphaned children? We know that it’s possible (though it has become more difficult) to send money to specific North Korean recipients. If so, a trusted intermediary, such as the stay-behind relative of a refugee in the South, can be taught to screen patients, and to pay doctors to see and treat the patients whose need is greatest.

This certainly isn’t a long-term solution. Paying doctors to treat some poor patients will put additional demand on a limited supply of providers, and drive up the cost that other poor North Koreans pay for them. Because the regime is only willing to provide so many doctors, it would also draw more unqualified healers into the medical services market. That’s why it will eventually be necessary to increase the supply of medical providers. How can that be done in a closed system like North Korea’s? One solution may be telemedicine, which American doctors are already using to diagnose and treat patients in distant, far-flung, underserved communities now, and which NGOs are also exploring as a way to provide medical services in other poor countries.

In the case of North Korea, the extra doctors might be volunteer physicians in South Korea, the United States, or Europe. It is already possible (though, again, increasingly difficult) for North Koreans to call across their country’s northern border by piggybacking on Chinese cell networks. There is no good reason why South Korean cell networks couldn’t also expand into North Korea, and open a second front in the war against Pyongyang’s information blockade. If the network existed, the markets would soon provide the phones that could utilize that network. In the same way that North Korea’s guerrilla financial system can send money to recipients inside North Korea, the market could develop the capacity to send medicines, even prescriptions, to those in need of them.

There are, of course, technological challenges: telemedicine requires the doctor to be able to speak with the patient, and often, to see high-resolution imagery of the patient to observe symptoms. In the short term, full-service telemedicine is probably asking too much. Pyongyang is cracking down hard on North Koreans who make calls over the Chinese network, and one assumes that it would crack down even harder on those who used a South Korean network. But whatever the limitations on the imagery and video those phones could take and upload, it would be a vast improvement over what North Koreans have now: nothing.

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Must read: Jieun Baek on how North Koreans beat the border blockade

Admittedly, Baek’s explanation of the North Korea’s guerrilla banking system isn’t the first I’ve read, it’s only the best:

The next time Kevin talks to his mother, she asks him for $1,000. She gives Kevin a phone number. When he hangs up after about a minute, Kevin then calls that number and tells the stranger on the line that he got a call from someone (he uses a pseudonym to protect his mother’s identity). Every time, the phone number is different.

The stranger on the other line is usually a girl, a Joseonjok girl. The woman gives Kevin a South Korean bank account number, to which Joseph wires $1,000. He then sends the woman a text message using Kakao Talk (a Korean smartphone application that’s similar to Whatsapp), texting that he sent the $1,000. After receiving the message, the Joseonjok lady sends a message to another Joseonjok living in North Korea. This person will then notify Kevin’s family via their legal domestic cell phones that the money has arrived so that Kevin’s mother can go to that individual’s location, or the underground financial house, to pick up her $700 in Chinese RMB. The two middlemen take 30 percent of the requested money and split the commission. The whole transaction, part of the small underground financing system inside the country, can take place in as little as 20 minutes. [Jieun Baek, Politico]

It sounds very much like the hawala systems that initially caused the Treasury Department so much trouble after 9/11, until Congress tightened requirements that they be licensed and regulated. With a few upgrades, this could be the guerrilla financial system I’d advocated for here.

Baek also writes that refugees in the South can send medicine to their sick relatives in the North via smugglers. That has helped to ease the suffering caused by the collapse of North Korea’s state-run health care system, but there are risks that come with this, too. As Rimjin-gang recently informed us, some North Koreans who take smuggled medicines — often, medicines stolen from U.N. aid supplies — without a doctor’s advice are getting sick. If some way could be found to open the lines of communication wider, doctors in South Korea could volunteer to treat North Korean patients remotely, practicing what’s now called telemedicine.

Jieun Baek is writing some of the most thought-provoking work on how to “engage” with the North Korean people I’ve yet read. I’ve added her to my blogroll, and must keep a closer eye on what she writes.

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North Korean women who turned to prostitution to survive believe that opium

… protects them from STDs, and then end up addicted, according to this article in New Focus. Do you suppose the regime would acknowledge either prostitution or drug abuse enough to allow a public health education program to counteract this dangerous myth? On the other hand, if an NGO were to purchase some ad time on Radio Free North Korea or Open Radio for North Korea, it could deliver that message directly to an audience that desperately needs to hear it.

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WHO Knew? North Korea’s health care system is nothing to envy.

north-korea-poster-560.jpgSo, aside from stultifying political repression, famine, forced labor, criticism sessions, neighborhood spies, propaganda speakers in every home, prison camps for dissenters, and the occasional public execution, what has Kim Jong Il ever done for us? Ask any Chomsky-parroting career grad student in the East Bay and she’ll say, “universal health care!”

Alas, those neocons at Amnesty International have come to crush their tiny, misshapen hippie souls with this extensive report:

The North Korean government has failed to adequately address the country’s ongoing food shortages since the 1990s. This failure has led to the current critical situation in which the population faces severe health problems associated with malnutrition. Compounding these problems, North Korea’s government has failed to provide adequate resources for its health care system, which as a result is wholly unable to cope with the growing number of illnesses and diseases of a population weakened by hunger.

According to the WHO, North Korea spent less than US $1 per person in 2006.

You do know what this means, don’t you? It means that Margaret Chan isn’t just a tool and an imbecile, she’s a liar. Granted, those options aren’t mutually exclusive. Either way, she should resign from her position:

In fact, North Korea had one of the lowest recorded per capita total expenditure on health in 2006 of any country in the world.105 The state’s paltry expenditure on health, in spite of the urgent need for medical training, access to medicines and public health education, violates North Korea’s obligation to provide for the basic health of its population.

Let me just express my relief that Amnesty can find North Korea on a map, because by the second year of any Republican president’s term, the question does tend to arise. And with that obligatory criticism dispensed with, Amnesty has actually written a good, hard-hitting, report.

The Associated Press picks up the Amnesty report and summarizes it this way:

North Korea’s health care system is in shambles with doctors sometimes performing amputations without anesthesia and working by candlelight in hospitals lacking essential medicine, heat and power, a human rights watchdog said Thursday.

North Korea’s state health care system has been deteriorating for years amid the country’s economic difficulties. Many of its 24 million people reportedly face health problems related to chronic malnutrition, such as tuberculosis and anemia, Amnesty International said in a report on the state of the health care system.

Oh, and North Korea’s universal, free health care is neither, but you knew that:

North Korea says it provides free medical care to all its citizens. But Amnesty said most interviewees said they or a family member had given doctors cigarettes, alcohol or money to receive medical care. Doctors often work without pay, have little or no medicine to dispense and reuse scant medical supplies, the report said. “People in North Korea don’t bother going to the hospital if they don’t have money because everyone knows that you have to pay for service and treatment,” a 20-year-old North Korean defector named Rhee was quoted as saying. “If you don’t have money, you die.”

But on the plus side, positively no death panels!

Many interviewees said they had to walk as long as two hours to get to a hospital for surgery, said Norma Kang Muico, an Amnesty researcher and author of the report. North Koreans are numbed to what was wrong with the health system, because “things keep progressively getting worse, or even staying the same but at that low level,” she told reporters in Seoul on Thursday. Amnesty blamed ….

Wait, wait. Don’t tell me. International sanctions that starve North Korean babies and infringe on its sovereignty! Right?

…. failed or counterproductive government policies and said North Korea should cooperate with aid donors to ensure transparency in the distribution of food assistance and guarantee that medical personnel are paid adequately.

Damn neocons.

Much of Amnesty’s report is about the root cause of the poor health of its people: the lack of food. Amnesty’s original report contains a good history of the regime’s frustration of transparent food aid distribution and monitoring, and this:

North Korea has an obligation to accept international humanitarian assistance when it cannot meet the needs of its own people. But the North Korean government has refused some urgently needed humanitarian assistance on political grounds.32 For example, in May 2008, the US government resumed food aid to North Korea for the first time in three years. But due to strained relations in March 2009, North Korea refused to accept any further food aid from the US and told five US humanitarian aid organizations33 to leave the country by the end of the month. In March 2010, the US government said it would consider resuming food aid to North Korea if the North retracted its refusal of humanitarian assistance.34

One 24 year-old defector from North Hamgyeong relates how he was hitching a ride on a freight train and fell off. Big mistake. His ankle was crushed, and the treatment wasn’t much better than the accident:

“Five medical assistants held my arms and legs down to keep me from moving. I was in so much pain that I screamed and eventually fainted from pain,” said the man, identified only by his family name, Hwang. “I woke up one week later in a hospital bed.”

Eaten yet? Depending on your answer, you may want to skip past this part:

Na, a 21-year-old man from Onsong, North Hamgyong province, worked with his mother from the age of 8 to 12 years at the local coal mine. Since the early 2000s, he suffered from chronic digestive problems and tried to ameliorate his pain through self-medication by taking aspirin65 at night. He recounted how intestinal or maw worms (Ascaris lumbricoides) “30cm in length” emerged from his mouth. Although Na took anti-worm medication, the worms continued to re-appear due to “poor hygiene”. According to him, the low level of hygiene was due to his work environment, coupled with living in close proximity to farm animals, open sewer and waste that was not properly disposed.66

A 2010 report by South Korea’s Korea Centres for Disease Control and Prevention (KCDC) looked at medical exams of North Korean settlers who had arrived in South Korea in 2008. It revealed that nearly half of young North Koreans, aged between 13 and 18, were infected with parasites, such as maw worms. The overall rate of infection for that year was 29 per cent.

I’ll give you one last quote, from Barbara Demick of the L.A. Times, who has written plenty about the quality of North Korean health care in her recent book:

“I was screaming so much from the pain, I thought I was going to die. They had tied my hands and legs to prevent me from moving,” said a 56-year-old woman from Musan who had an appendectomy performed without anesthesia. [….]

A 17-year-old girl from Musan, a city near the Chinese border, who defected in February of this year said people often used illegal drugs, particularly “ice,” a highly addictive methamphetamine that is manufactured inside North Korea. “You do drugs if you have a cold, a stomachache, for whatever is wrong,” said the girl, who was interviewed in March by The Times. The Amnesty International report also said North Koreans were using morphine and opium derivatives to medicate themselves for lack of proper pharmaceuticals.

What else emerges from the report is that North Korea’s medical system is a hollow infrastructure — one with a lot of clinics, doctors, and nurses, but no instruments, supplies, equipment, or medicine, and one where the only people who get treated are the privileged or the new rich. That means it’s a system that could be coopted. An underground religious, political, or humanitarian group could help its supporters or beneficiaries inside North Korea get medical care by paying doctors and nurses with money and medicine. The doctors and nurses need the money, and initially, they wouldn’t know and might not care who was paying the bills, at least until they realized they were also incriminated.

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Biting the Hands that Feed Them

Via Open News for North Korea, we learn that the regime is blaming the H1N1 outbreak in North Korea — which has killed six students under 18 — on South Korea, the country that offered immediate and unconditional aid to help control said outbreak. After all, all bad things in North Korea come from beyond its borders.

According to a source, North Korean Health Department has stated that the new strand of flu spreading in North Korea originated from South Korea. According to the source, directors of North Korean universities, middle schools, and elementary schools, as well as local health officials received a message on the new strand of flu through phone and internal messages. They state that the new strand of flu spreading quickly throughout North Korea originated from South Korea through Kaesung Industrial Complex, and all universities will be off from 2pm, December 5. [Open News]

It’s too bad Roh Moo Hyun isn’t alive to see how much good will and co-prosperity the Sunshine Policy has built over the years. Sure, it cost a few billion dollars, but with Uncle Sugar ultimately footing much of the bill for South Korea’s defense anyway, subsidizing a failing state on your border and making sure there’s a need for that subsidy only keeps the money flowing through the Hub of Military Welfare. Hey, it’s a win-win. Unless, of course, you’re an American taxpayer. Or a North Korean.

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H1N1 Outbreak in North Korea Defies Perfection of Its Universal Health Care System

The outbreak is serious enough that North Korea has ended the school year prematurely, but still isn’t acknowledging the outbreak, though there are posters springing up advising the people to practice basic sanitation (though I wonder how many have clean water). The Daily NK suggests that shortages of coal and firewood to heat the schools are another reason for the closures.

Shockingly, North Korea’s superior universal health care system hasn’t been effective at stemming the spread or diagnosing H1N1, according to the Daily NK. This is astonishing. After all, noted North Korea expert Christine Ahn has informed us that “[t]he World Health Organization and other United Nations agencies have praised their delivery of basic health services, noting that North Korean children were far better vaccinated than American children, and that life expectancy rates in North Korea surpassed that of South Korea.” How can I possibly make sense of this?

Meanwhile, South Korea is offering unconditional aid to stop the outbreak. As long as the aid isn’t cash, that is good. The latest word is that North Korea will accept the South’s offer.

More on past outbreaks of communicable disease in North Korea here.

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