Critique of AI Report: The Crumbling State of Health Care in North Korea

by Marilyn Weingartner, retired Public Health Nurse, 4 August 2010:

At the end of April, World Health Organization Director General Dr. Margaret Chan visited Pyongyang and came back with a report that seemed to praise the DPRK for its universal health care system. (Read: Press briefing at WHO headquarters, Geneva) Her report has been widely criticized for painting too pretty a picture of realities on the ground in North Korea. Indeed, she should have been more careful about commenting on the size and weight of people she observed on the street in Pyongyang. Surely the lack of obesity Dr. Chan observed cannot be attributed only to the fact that North Koreans do a lot of walking!

In mid-July Amnesty International (AI) issued a report about “The Crumbling State of Health Care in North Korea” that paints a dismal picture about health care in the DPRK. This is an approach based on a second-hand relationship with DPRK, since AI does not have direct access to work inside the country. The report relies on information provided through interviews with expatriate North Korean refugees/defectors.

Whereas the access Dr. Chan had was almost entirely limited to the relatively prosperous capital city, AI’s sources were almost entirely from the province of North Hamgyong, a region that is farthest away from the capital. The AI report reveals what we already knew about the relative poverty of the northeastern provinces, due to their remoteness, mountainous terrain and lack of arable land. Stories of survival from that region have always been horrendous, and this is reflected in the interviews.

Initially, I was pleased that the urgent issue of health care has been getting the attention it deserves and needs. But as I read the AI report, I couldn’t help getting angry, not at the DPRK regime, but at the writers of the AI report, who in my estimation have missed a golden opportunity to do something positive for the people of North Korea.

As a health care worker who lived and worked in the health sector in the DPRK from 1997 to 1999, I have seen the best and the worst imaginable. I can relate to the conditions described in the AI report, because much of what is written there I have experienced with my own eyes. But what is the purpose of this report? How does this report differ from the one Amnesty has already issued in 2004? Why now?

One can criticize Dr. Chan’s excessive optimism about the North Korean system, but the WHO, for all its faults, is concerned about opening doors and marshalling the resources necessary to improve a crumbling medical infrastructure. But how will the AI report help the people on the ground? Apart from a rather gratuitous admonition that donor countries should “ensure that the provision of humanitarian assistance in North Korea is based on need and is not subject to political conditions,” the conditions under which such assistance is to be rendered merely strengthen the impression that all aid is tied to political considerations.

There are two aspects that I feel compromise the usefulness of the report:

Amnesty goes to great lengths to justify its competence in the field of health care. It seeks to convince us that the crisis in health care is a human rights issue. There are ample references and quotes from international human rights law, and like the prosecution in a court of law it indicts the DPRK government for failing to meet international standards. Does this approach help to determine how to best serve the needs of ordinary Koreans with the help of and sometimes in spite of their (and often our own) governments?

The report reminds us that most potential donors withhold aid because it “would not reach those in greatest need.” Yet there is no mention of the sanctions in place—some of them since the Korean War—that directly impact the provision of assistance even if access problems were completely resolved. One of these is a ban on “dual-use” exports (i.e., civilian goods that could be adapted to military purposes), which directly affects medical equipment.

The Amnesty report blames Pyongyang for a shortage of syringes at hospitals. In the 1990s Iraq suffered from a similar shortage because of concerns that they might contribute to Iraq’s WMD programs. Supplies of syringes were held up for half a year because of fears they might be used in creating anthrax spores. Tens of thousands of Iraqi children died as a result. Why does Amnesty not draw attention to this devious political tactic as a human rights issue?

References to the DPRK’s “economic problems” over-simplify the effects of international sanctions and isolationist policies on the capacity of the country to re-build and restore the elements needed for a functioning health care system. I use the word “restore” because, as Dr. Chan tried to clarify (unfortunately rather awkwardly), the elements are there. Clinics, for example, are present down to the smallest “ri” (county). But the clinics are bare, cold, and the staff are out in the fields trying to make ends meet and to feed their families. When the AI report exhorts the DPRK that “Functioning public health and health-care facilities, goods and services, as well as programmes, have to be available in sufficient quantity within the State party” the report shows the kind of disrespect that has turned well-meaning North Korean health care workers against some of the NGOs that previously worked in the DPRK. One experienced MD of my acquaintance stopped going to workshops because he was personally offended by a young foreign NGO worker who tried to lecture him about how to run the pharmacy at his hospital.

And this brings me to my second point:

With their macro-view of DPR Korea, the AI report misses the humanity of the health care workers and their patients who suffer from the crisis. It offends the dignity of those who are doing everything within their power to serve their people in the field of health care. When Soviet help was still available to the DPRK, medical staff had access to reasonably modern medical education and technology. Doctors often had Russian as their second language because they studied at Russian medical schools. AI cannot notice the heartbreak of these health care professionals who created a system that in its heyday was indeed the envy of many countries, including the ROK. But within a lifetime that system has crumbled into the current critical state, through no fault of the health care workers.

I have met many doctors who now struggle in good faith to make medicines from wild plants for their patients, and who are left to try to establish a diagnosis with a worn out stethoscope. The Institute for Health Information in Pyongyang has a wealth of health information researched and ready for printing and distribution. All that is missing is ink and paper to print it on.

It’s easy to blame the regime for a “lack of commitment to transparency”. (Are we still talking about DPRK?) Where is the capacity for AI to point out the tiny steps taken by WHO and other organizations, for example to improve access to medical attention by providing bicycles for doctors and midwives? Or to improve the capacity of the DPRK to produce their own TB medicines by providing window glass for the Pharmaceutical Factory in Pyongyang?

As far as I am concerned, this report just adds another voice to the current cacophony of criticism that serves only to entrench division among those interested in helping North Koreans and obscures the true nature of the dilemma facing the DPRK. This kind of debate does not lead to insight about how to respond to the situation of doctors and nurses and their patients and family members. Meanwhile, people continue to suffer.

Will the Amnesty report lead Canada to establish exchange programmes for health care workers, so that they can visit our facilities, so they can upgrade their knowledge base, or even just to learn English? Or will the report simply confirm to the Canadian Government that limiting resources and access to the DPRK is a reasonable policy?

During the Nutritional Survey of 1998 the driver of my team emphasized to me that if there were 1 bean and 5 Koreans, that bean would be divided among them. Today, unfortunately, the old song about “nothing from nothing is nothing” is as true as ever.