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The price of isolation
Humanitarian aid
 in North Korea
by  John Owen Davies




The Democratic People's Republic of Korea is wracked by crippling economic problems following the break-up of the Soviet Union and, since 1995, ravaged by a vicious cycle of floods and drought.
In an attempt to warm often freezing wards in winter, and in the absence of readily available coal and wood, the director of Huichon City Hospital says his staff heat soot - "coalsmoke pieces" - gathered from local chimneys. To help retain any warmth, cracked glass windows are covered with polythene in spartan wards, fitted out with makeshift beds covered by threadbare blankets. Windows in the sombre operating area, which lacks effective anaesthetics for all but minor surgical procedures and with only a minimum of instruments, receive the same treatment.

But cold is not the only problem facing the director, Chon Tong Sik, whose 76-doctor hospital is in a northern area of the Democratic People's Republic of Korea (DPRK). A lack of drugs, food and transport forces some patients to stay at home.

Once the envy of many developing countries, the country's public health system is in serious decline. The decay - mirrored in the pharmaceutical, energy and agriculture sectors - is a manifestation of DPRK's economic decline, driven by the break-up of the Soviet Union and a succession of natural disasters.

Floods threaten food security 

DPRK, which has never been able to feed itself, suffered what some commentators referred to as a 'famine' during the mid-1990s. The widespread floods of 1995-96 ruined many hectares of farmland, destroyed dams and damaged mines. Since then, the country has been the recipient of the longest sustained UN food emergency programme in history.

Many relief workers with experience in DPRK put deaths caused by the series of floods and malnutrition at between 800,000 and 1.5 million. Some estimates for the period 1995-98 have been as high as 3 million lives lost.

Figures given by one DPRK official suggested 222,000 had died since 1995. "We think this is on the low side," said David Morton, the UN representative and resident coordinator in Pyongyang.

And there is more bad news for DPRK's hard-pressed 22 million people. A senior official with the country's Flood Disaster Rehabilitation Committee (FDRC), which oversees and coordinates the work of relief agencies, said the amount of rice - or its equivalent - for office workers, labourers and officials was being reduced.

These reductions are despite an improved harvest during October-November 1999 of 4.28 million tonnes of grain and rice - around 700,000 tonnes more than the previous year - which reverses a downward trend seen since the 1995 floods. But DPRK officials say the country needs around 6.5 million tonnes a year to be self- sufficient.

Scant drug supplies and equipment

"We use antibiotics for emergency cases. It is very difficult for doctors to know who to give treatment to and who not to treat. Because of malnutrition, people can get some disease immediately," said Huichon City Hospital's director Chon, adding that common colds, bronchitis, pneumonia and cardiovascular complaints were regular problems.

Infectious diseases once under control in DPRK are making a comeback. The World Health Organization (WHO) says that while tuberculosis remains one of the most serious public health problems in DPRK, with an estimated 40,000 new cases a year, malaria has re-emerged in southern provinces during the past three years, with a "significant increase" in the number of cases in 1999.

While DPRK's public health system is stretched alarmingly, foreign experts with first-hand knowledge do not believe the situation is yet desperate. WHO's coordinator in Pyongyang, Eigil Sörensen, said: "I would not say that the public health system in DPRK is near to collapse."

But, he added, "The problem is that for the past 10 to 15 years they have suffered from a degradation of the health-care system, with basic problems with water, electricity and heating. Then there is a lack of reserves and an economic decline."


Humanitarian needs and principles collide? 

For international non-governmental organizations (NGOs), there are moral questions related to working in DPRK based on humanitarian values. Should agencies maintain unquestioning support for a country run along tight military lines? Does restricted access to beneficiaries and to distribution networks threaten transparency and accountability enough to justify agencies pulling out? Can an NGO policy of advocacy survive and, if so, how can it be operated?

Several NGOs have already left DPRK, most notably Médecins sans Frontières (MSF), the 1999 Nobel Peace Prize laureate, in a blaze of publicity in 1998. Other NGOs who have left, mainly over issues focusing on access and monitoring, include Médecins du Monde, Oxfam and Action contre la Faim.

James Orbinski, MSF's international president, said: "In large measure, we found it impossible to deliver humanitarian assistance in an impartial, independent fashion and we found that it was impossible to target the most vulnerable people that we knew to exist but were unable to access." Orbinski alleged that Western foreign policy was using humanitarian assistance as a form of political leverage.

MSF's departure, more than any other, has raised the issue of whether humanitarian organizations should stay on and, quietly, work to continue making valuable inroads - or whether leaving should be the path. Several agencies appear to have opted for the former.

The UN's David Morton, in Pyongyang for nearly two years, believes the situation has improved. "It has been very difficult," he said. "We think we have a fairly good idea of what the situation is and what is going on. We have access to 75 per cent of the area, which is 85 per cent of the population."

International impressions of what is happening in DPRK depend largely on what people are shown, almost always under strict supervision. Forty-eight of DPRK's 212 counties are normally off-limits to humanitarian workers, making aid monitoring difficult. An estimated 15.6 percent of the population lives in these 48 counties, mainly in mountainous land with limited farming possibilities - and it is in such regions that some aid workers believe the worst malnutrition may exist.

Another problem area with some aid suppliers has been allegations that some international aid has been diverted to the army. This has been denied as "a lie" by DPRK's official KCNA news agency. "We will never be able to be absolutely sure where the aid goes. But we know that … at least a very high proportion of it goes to where we think it has been going, where it is supposed to go," Morton said.

Staying on pays off 

The Federation, which works in concert with the DPRK Red Cross society and supports 1,678 hospitals and clinics, has reiterated that it has no intention of leaving the country and will stay there for as long as necessary.

Maybe the world is looking too much for obvious results from humanitarian relief going to DPRK. There is another side, usually noticed only by people who have worked in the country. "I think the people are suffering so much that some of them will take the risk to tell you how difficult it is for them. They know you can tell the world," said the Federation's Corinne Baas, a health delegate in DPRK. Simply being there may be the best form of advocacy.

The extent to which DPRK has opened up since 1995, when the country requested aid for the first time, must not be underestimated. The Red Cross is providing official links between the two Koreas, sometimes through contacts between the respective national Red Cross societies.

But change in the DPRK government's attitude to the way relief is delivered will not be fast. "I think there will be little changes slowly but surely," said one long-time Western resident with a relief organization. "This is a place where there is no significant overnight change. You are not going to suddenly wake up one day and find a McDonalds."

John Owen Davies
John Owen Davies, a consultant writer, travelled to DPRK for the Federation. This article is abstracted from a chapter he contributed to the World Disasters Report 2000.

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