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“First Do No Harm.” The Impact of Sanctions on Public Health in North Korea

January 15, 2020
Volume 18 | Issue 2 | Number 3
Article ID 5338

Kee B. Park, MD, MPH, is a lecturer on Global Health and Social Medicine and Director of the Korea Health Policy Project at Harvard Medical School. He also serves as Director of the North Korea Programs at the Korean American Medical Association, and has led over 20 delegations to North Korea since 2007 to work alongside and collaborate with North Korean doctors in the DPRK. Dr. Park obtained his medical degree from Rutgers University, trained in neurosurgery at the Temple University Hospital in Philadelphia, Pennsylvania, and earned a Master of Public Health from Harvard’s T.H. Chan School of Public Health.

 

Abstract

Korea Policy Institute (KPI) Executive Board Member Haeyoung Kim spoke with Dr. Kee Park on December 9, 2019 about his work in the DPRK, the unique features of the North Korean health system, and how geopolitics, above all the US travel ban and sanctions on trade impact public health and human security in North Korea. Dr. Park documents the severe challenges to health care in North Korea, the surprising strengths of the health system, and the contributions of a small group of American physicians of Korean descent in aiding health care in North Korea over the past twelve years.

 

 

[Haeyoung Kim] Dr. Park, can you begin by sharing with us a bit about your personal background and how you came to be one of the few American doctors providing health care in North Korea? 

[Dr. Kee Park] I’m a neurosurgeon by trade. Right out of residency, I went into private practice in a small town south of St. Louis, Missouri, and I loved being a community-based neurosurgeon. But, a few years into it, I and a few Korean American neurosurgeon friends who had been in practice for some time found ourselves wondering if there was something else we could do to help others. After some discussion, we settled on the question: how could we help North Korean neurosurgeons? Not really knowing if they needed help or not, we made some assumptions and wanted to reach out to them. This was in 2006. 

American Physicians Medical Exchange With North Korea

[Haeyoung Kim] What led you to decide that it was important for you, an American doctor, to reach out to North Korea? 

[Dr. Kee Park] My state of mind in 2006 was not like it is today. I’ve had 12 years now to familiarize myself with North Koreans and the country, especially their health and things that effect their health. In 2006, I knew nothing about what was happening inside North Korea, but I suspected that things were difficult. Later on, I found out how difficult things actually were. But, in 2006, I only had an inkling. Being Korean with an ability to help, I felt a sense of responsibility. It’s like helping a family member. If a family member were struggling, you would go help them first before you stand by and watch strangers offer help. It was that kind of feeling. Koreans are of one country; we share the same culture. Because I’m Korean, I felt and feel this sense of oneness, so it was up to me to do what I could.

[Haeyoung Kim] How did your engagement with North Korean doctors begin?

[Dr. Kee Park] In 2007, we were introduced to and met with North Korea’s diplomats at the DPRK mission to the United Nations (UN) in New York. We started discussing the prospect of working with North Korean neurosurgeons and came up with the idea to invite a delegation of North Korean neurosurgeons to the US. This was during the Bush administration. We—the Korean American Neurosurgical Society—contacted the Korea Desk at the State Department and said that we wanted to invite a delegation. We had a nice series of communications, they eventually sent us the application, the North Koreans filled everything out, we submitted it all, and we waited. It wasn’t until one week before their proposed scheduled travel date out of Pyongyang that we received notice from the State Department saying their visas had been approved. They also had conditions on their visas, including one that said all meetings in the US with the North Korean delegation must be closed. The press could not be notified. We all accepted the terms, and we were able to host the three-member delegation in the US in 2008. Two were neurosurgeons and one was not in the medical field, but later became a counselor at the DPRK mission in New York. During their visit, they met with physicians in Missouri and New York, and attended an annual meeting of neurosurgeons in Chicago. We also held a private reception and a number of Korean American neurosurgeons attended to meet with them. Also, just before the delegation arrived, the DPRK mission in New York asked if we wanted to go to Pyongyang. Of course, I jumped at the chance. September of 2007 was my first trip to North Korea, and I’ve been going back twice a year since. 

[Haeyoung Kim] How large have your delegations to North Korea been and who are the participants? Has the 2017 US ban on American citizens traveling to North Korea greatly impacted your efforts to practice in the DPRK?

[Dr. Kee Park] At one point, over the course of the twenty plus trips we have now taken, our group was as large as 25. It has fluctuated, and the group has gone down to 2 or 3 at the most including myself since the travel ban. It’s difficult to get people to go through all the trouble that you need to go through these days to get there, and you might not be able to go. The State Department can deny our passports, and they sometimes have. Since the travel ban, we have requested to go 4 times. We were denied once and granted permission the other three times. Our groups have been composed of doctors with various specialties. The way it works, we set them up with their counterparts in North Korea. If they are ophthalmologists, we pair them up with North Korean ophthalmologists. If they’re cancer surgeons, we pair them up with North Korean cancer surgeons. Then, the doctors can figure out where North Korea is at and what kind of support they’re able to provide.

[Haeyoung Kim] In 2010, World Health Organization (WHO) Director-General Margaret Chan made a visit to North Korea and reported that the health system has things that the developing world would envy. These comments were a dramatic departure from the 2001 remarks offered by her predecessor, Gro Harlem Brundtland, who reported that North Korea’s health system was near collapse. How can we make sense of these dramatically different takes? If these statements are accurate in any way, what happened in the intervening years to impact the health system?

[Dr. Kee Park] In 1995, things crumbled in North Korea because of the famine. Everything fell apart. They abandoned the public distribution system. People were dying of starvation. The health system suffered. North Korea has been on a recovery track since the late 1990s. So, in 2001, being “near collapse” is not an unreasonable description. The mid-to late-90s is also the period when the North Korean government issued an official appeal for international assistance. They opened up to receive international aid including from the UN and a number of countries that had fought the DPRK in the Korean War, which was historic. UN agencies started entering North Korea, and American NGOs went in. A number of agencies and international organizations said they would of course help, and began establishing offices inside of Pyongyang. Many are still there.

 

The North Korean Health Care System

[Haeyoung Kim] How would you assess North’s Korea’s health care system today? What sorts of challenges do doctors in North Korea face?





Dr. Kee Park and members of the Korean American Medical Association performing surgery alongside their North Korean counterparts in Pyongyang, May 2016.

[Dr. Kee Park] Let me qualify my statement. I’m someone who sees things periodically in North Korea, and I try to patch things together much like the parable of a blind man feeling an elephant from different places. With a patchwork of data points, I can say I think this is what things look like. What I can deduce is that North Korea’s health care system is highly organized and centralized. They have a section doctor system, which assigns one doctor to an area containing several hundred individuals for whom that doctor is responsible. They also have ri-clinics (rural community or village clinics), district hospitals, regional hospitals, and specialty hospitals. They have one of the highest densities of doctors, nurses, and healthcare workers that I’m aware of. They certainly have plenty of doctors and nurses, meaning that the government is investing in and spending money on pre-service education. Education is free in North Korea, so the government is investing money to insure that every nurse and doctor gets trained and educated. The government is also paying their salaries. So, the government spends quite a bit of money on the health workforce. 

Costly supplies, though, are posing big problems. North Korea just doesn’t have ready access to certain things. So, supplies get reused and North Korean healthcare workers find ways to cut costs. Single-use scalpels, gloves, and gauze, for instance, are cleaned and sterilized and reused. Because of this, doctors and hospitals are having a difficult time. Medical equipment like x-ray machines are hard to repair once they break because it’s difficult to import necessary parts. 

At the same time, North Korea is trying to invest where it can. I’ve seen North Koreans invest in renovating operating rooms at Pyongyang Medical College over the last year or so. They are also investing in new technologies. I have seen an artificial knee joint they have developed, which they are manufacturing and implanting in patients. They have a domestic ultrasound machine that they’re producing for use in local hospitals. 

I would also characterize North Korea’s health system as highly efficient, if not one of the most efficient health care systems. With the sanctions, they have limited resources and face challenges. But, it’s a highly efficient and cost-effective health system. I can give you an example: North Korea wanted to do a public health campaign for tuberculosis detection and treatment. With the Global Fund grants that UNICEF and the WHO offices in Pyongyang received, the Ministry of Public Health was able to achieve one of the largest reductions in mortality from TB at half the cost of other countries. This gives you an idea. Also, consider their maternal mortality ratio, which is a Sustainable Development Goal target for health. The target for developing countries is to reduce mortality below 70 maternal deaths per 100,000 live births by year 2030. North Korea has already hit that target. In fact, they’re below that number. 

People have asked if I believe these numbers. In the 1990s, a fair argument could be made that the numbers coming out of North Korea were not reliable. But, UN agencies have been inside the country, working with the National Bureau of Statistics, and verifying these figures such that most people agree that the numbers are pretty accurate. It has been a function of time, and I think the numbers are now much more accurate. So when people question these numbers, I think it’s because they don’t understand the evolution of the data. It’s much better than it was, and I find it credible. 

 

US Sanctions on North Korea: 

[Haeyoung Kim] The US has imposed sanctions on North Korea since the Korean War, and the United Nations began imposing sanctions in 2006. In what ways has the sanctions regime against North Korea impacted your work?

 


Dr. Kee Park and members of the Korean American Medical Association performing surgery alongside their North Korean counterparts in Pyongyang, May, 2016

[Dr. Kee Park] We knew that the US had executive orders and embargoes in place when we were working in 2007 and 2008. We also understood back then that there was general license given to humanitarian aid workers like us when we went there. We were able to work with a certain amount of latitude. Based on this, we were able to provide equipment and sent a container of surgical equipment in the early 2010s. But, then the sanctions started to be ramped up. I would say the inflection point was 2016-2017, which of course coincided with North Korea’s nuclear weapons development program. They went from “smart” sanctions to “total” sanctions and started blocking the importation of fuel—an almost complete embargo. How do you operate a hospital, how do you drive ambulances, how do you move patients around without fuel? Also, consider farm machinery. How do you power farm machinery without fuel? When fuel imports are reduced this drastically—with only one-tenth of what formerly entered the country now coming in—there will inevitably be a rationing system and prioritization of how available fuel is used. 

Then, of course, all major imports and exports were banned. And, compounding the issue, there are those individuals who are employed by these industries, and it’s reasonable to assume that their incomes were markedly impacted. Since most North Koreans supplement their food rations provided by the state’s central distribution system with food purchased from the markets, this inevitably resulted in greater food insecurity. 

So sanctions were ratcheted up in 2016-2017, and then the travel ban on US citizens traveling to North Korea was imposed in 2017. Around that time, we started to hear stories from UN agencies about how they couldn’t conduct their work anymore and that they were unable to send money into the country. 

[Haeyoung Kim] The UN Security Council makes case-by-case exemptions for humanitarian-related items. Is this sufficient to allow humanitarian organizations to deliver aid?

[Dr. Kee Park] Yes, there is an exemption process, but it doesn’t work very well. Before the more rigid sanctions were launched, aid was getting in. Then, it came to a trickle—not a standstill, but a trickle. Then, one by one, case by case, the UN Security Council Sanctions Committee would approve or deny shipments. And, it’s not just the UN Security Council sanctions resolutions aid workers have to face. The US has its own unilateral sanctions, which involve the Bureau of Industry and the US Treasury. The Bureau of Industry issues import and export licenses, and you have to obtain their permission to bring anything into North Korea. Then, to use US money on North Korean goods, you have to a get a license from the Office of Foreign Assets Control at the US Treasury. They give you a time-bound license, maybe two years or so, and you have to reapply thereafter. But, they’re very specific about the kinds of activities and transactions you’re allowed to conduct. And each agency applies its own criteria for what it will and will not approve. It’s not standardized. In fact, the criteria are not really known, and I think it’s intentional, so the agencies can ratchet up or down the restrictions and apply pressure when politically opportune. 

 

Dr. Kee Park and members of the Korean American Medical Association in Pyongyang, May 2017.

Because of the bureaucratic red tape, we basically abandoned the idea of bringing in anything of value to North Korea. The Korean American Medical Association is not an NGO; we’re a professional society. We don’t have the resources to navigate these kinds of bureaucratic hurdles. Only large groups like World Vision and the UN agencies, organizations with deeper pockets, can hire the necessary lawyers and administrative staff to handle the paperwork and go through the lengthy process to acquire licenses. 

The Human Cost of US and International Sanctions

 

Joy Yoon, whom I worked with to co-author the report commissioned by the Korea Peace Now! campaign titled The Human Costs and Gendered Impact of Sanctions on North Korea, has gone into detail about what the small NGO she co-founded, Ignis Community, has experienced throughout this process. She has shared how long it has taken to jump through the bureaucratic hoops and her fears that the delays experienced by her organization because of the barriers imposed by myriad sanctions have led to deaths among patients they have been treating. In fact, I think one did recently die. 

To the UN’s credit, though, the Security Council Sanctions Committee is reviewing requests and making decisions within 2 weeks of requests to provide aid. They’ve sped the process up. It used to take longer. But, we shouldn’t have to ask for every case. The fact that humanitarian organizations have to ask for permission to provide aid to the vulnerable and the marginalized people of North Korea is a travesty.

[Haeyoung Kim] According to the United Nations, the measures imposed by UN resolutions are “not intended to have adverse humanitarian consequences for the civilian population of the DPRK.” Sanctions should not aim to negatively impact or restrict “the work of international and non-governmental organizations carrying out assistance and relief activities in the DPRK.” As a practitioner on the ground in North Korea, can you help our readers make sense of how these stated intentions don’t reflect the practice of implementing sanctions? 

 


Dr. Kee Park and members of the Korean American Medical Association alongside their North Korean counterparts in Pyongyang, May 2017.

[Dr. Kee Park] Yes, all of these sanctions include that line: adverse humanitarian consequences are not intended. In reality, though, they undoubtedly do have adverse humanitarian consequences. It calls into question the sincerity of the sanctions writers. Can they really mean that given the fact that it’s pretty clear from the ground that sanctions adversely impact the humanitarian conditions in North Korea? Perhaps that line provides political cover. I cannot imagine that those who impose sanctions don’t know how sanctions play out, especially since they have been through this recently with the sanctions imposed on Iraq. Joy Gordon has written the definitive book on Iraqi sanctions, Invisible War: The United States and the Iraq Sanctions. When you think about this coverage in the context of understanding the North Korean sanctions, it’s mind-boggling. It’s the same playbook. For instance, sanctions have blocked vaccines from going into Iraq. We all know the impact that would have. But, the senders of sanctions always turn it around and say it’s the government’s responsibility to provide these things. When the sanctions boot is on a government’s neck, applying a great deal of pressure, there’s a certain amount of dishonesty to expect that a sanctioned state can fully help its people. 

As an academic who does research, I know there are ways to estimate potential deaths related to sanctions without having to actually count the number of deaths. As a response, some may say we must discount certain figures if they’re just estimates. But, if what they’re saying is “Tell us how many people have actually died?” It’s too late if that’s the question being asked. These are children and women, and we should be counting how many people have died? Then, after having a death count, sanctions writers can then say, “Oh, you’re right, we’ve harmed innocent people and we should change our policies”? It’s way too late at that point. 

[Haeyoung Kim] You mention children and women. Are these the demographic groups hardest hit by sanctions? Your recent co-authored report on the human impact of sanctions against North Korea, titled The Human Costs and Gendered Impact of Sanctions on North Korea, notes that sanctions have “differential consequences for women’s security as well as their social and political rights.” Can you explain to our readers why sanctions have a disproportionate impact on women and children?

[Dr. Kee Park] Sanctions are worsening humanitarian conditions inside North Korea. This we know. Food costs have gone up, for instance, and international aid agencies working to provide clean water have faced delays or their efforts have been hampered significantly. These things directly affect the health of the people. If we look at water, we know that a lack of clean water causes illnesses. Children are hit the hardest. If you look at the cause of death of children under the age of 5, it’s infections like pneumonia and diarrhea. After the age of 5, it’s injuries and accidents. So, if clean water interventions are blocked or delayed through sanctions, the number of children that develop diarrhea will go up. And who are the primary caretakers of children when they get sick? It’s the mothers. Women are also the primary gatherers of water in North Korea. If no clean water sources are readily available, women have to go further to find it.

Food security is also getting worse, which we know. Which parent wouldn’t give food to their children first before they feed themselves? Both mom and dad, of course, would feed their children before themselves. But, women tend to be primary caretakers of children in North Korea. If you’re the primary caretaker, you’re feeding your child first. So, from a caretaker standpoint, women bear a disproportionate amount of the burden.

If you look at farming, more than half of North Korean farmers are women. Women now farm by hand, because there’s no fuel for farming machinery and broken machinery can’t be repaired because sanctions prohibit the importation of necessary parts. So, women have to work harder to get the same yield, bearing a disproportionate burden.

And, there are industries that are impacted by sanctions. One industry particularly impacted is the garment industry, which is a leading export industry. Textiles now can no longer be exported from North Korea. The majority of workers in the garment industry are women, and all of a sudden they are without an income. For someone who is already poor, making them poorer puts them at a higher risk of all kinds of social dangers. 

Let me share a case from last year about UN agency programming that directly impacted mothers. The UNFPA—the United Nations Fund for Population Activities—works inside North Korea and they provide emergency reproductive kits to women. These kits contain critical treatments if there are any complications during delivery. You want to have these kits ready. They treat postpartum hemorrhages, eclampsia, and other kinds of emergency situations. We know that access to these kits reduces mortality. They save lives. Last year, in 2018, the UNFPA intended to provide these kits to 400,000 pregnant mothers in North Korea, which is great. However, what they were able to achieve was the delivery of just 4,000 kits. My colleagues and I have looked at the number of complications that could arise within that population and the expected mortality of not having these kits, and I think we calculated that 72 mothers would die if these kits were not available when complications arose. As a doctor, I’m outraged. Is this something that we as human beings can accept? Whether you’re a security person or not, it’s universally deplorable that we allow mothers to die. We have interventions and we have ways to save them. But, we can’t do much because of international security concerns, the global sanctions regime, and the sanctions process. But, that’s just a part of the problem. The other part is that the donors of these agencies are also facing diplomatic and political pressure from certain countries, and they are being asked to not donate. So, these programs face funding shortages.

[Haeyoung Kim] Speaking of second- and third-order consequences that result from sanctions, how about North Korea’s economic development, which they have been trying to recalibrate since the 1990s? Is the financial system impacted by sanctions?

[Dr. Kee Park] How do you develop an economy when you don’t have access to the global financial transaction system? When you can’t get any fuel? How do you develop an economy when exports are blocked? I think it’s clearly the intent of these sanctions to interfere with North Korea’s economic development. Let me talk about the financial aspect. There have been political and diplomatic efforts by the US and Japan to put pressure on countries that have typically donated to support humanitarian aid to North Korea. They’ve been asked to not donate anymore, which has been very effective. The UN every year comes up with a needs and priorities list of what’s urgently needed in North Korea and how much humanitarian aid is going to cost. Last year they appealed for 111 million US dollars, which would cover urgently needed clean water, food, and basic medical needs for 6 million people in North Korea. Donors are to provide funds for this, but in 2018 they only raised 24 million US dollars. That’s just not enough to cover programming costs. It may pay for the overhead and maybe some programming, but it’s not enough. In short, donors are being asked to not provide funding for humanitarian programming inside North Korea. 

The US has also been using unilateral sanctions to block any financial transactions dealing with North Korea. For instance, the World Health Organization has an office in Pyongyang and they have money to operate this office. The money, though, is in a bank account in India. So, to pay their rent and salaries to their local staff, they had to send the cash from India to North Korea. Then, the bank in India asked where the cash was going, and when they found out that the cash would be brought to North Korea, they refused to allow the transaction. They didn’t want to risk having the US Treasury shut them down because they’re allowing money to go into North Korea. So, they said they wouldn’t let the World Health Organization withdraw money if it was going to North Korea. Now, there’s no way to send money from India into North Korea because the banking channels have been closed. This is the same reason that FIDA—the Finnish International Development Agency—pulled out of North Korea after working in in the country for 20 years. Restricted financial channels and banking channels were making operations impossible. Most recently Handicap International—a very important organization that’s been working inside North Korea helping the disabled—decided to pull out. Handicap International is a European organization and they made a lot of progress in helping disabled people in North Korea. I’ve seen it firsthand. They’ve pulled out. We have to do something. Something needs to change. International organizations that seek to help ordinary people to survive in North Korea or anywhere else should not have to experience operational barriers. 

 

Do No Harm

[Haeyoung Kim] What specifically do you think could change? If you could offer a recommendation to the international community to improve humanitarian conditions in North Korea, what would it be? 

 

[Dr. Kee Park] Consider international humanitarian law in times of conflict. The Geneva Conventions is the perfect example. There are certain things that we as members of humanity have agreed on as being barbaric, including not harming civilians in times of armed conflict. It’s immoral and wrong to hurt civilians. We also have codes of conduct to define how we treat enemy combatants. For physicians, this means we don’t make distinctions between enemy combatants and our own. A patient is a patient is a patient. We first do no harm, and we treat the patient regardless. I think these norms are the best of what humanity has to offer. I mean, we shouldn’t have wars at all if possible but conflicts are a reality. But, we need to have codes of conduct, and not ones that only apply in times of armed conflict. We need codes of conduct for times when there is no active gunfire, as in the case of North Korea, but there may be security concerns. No one can rationalize harming the ordinary people of North Korea, but no laws are currently in place to hold sanctions accountable. This all really speaks to a need for the international community to develop something like the Geneva Conventions that apply when sanctions are being imposed.

[Haeyoung Kim] Is there anything thing you wish more Americans knew about North Korea? What could Americans and the Korean American community do to support your work in North Korea?

[Dr. Kee Park] I’m currently visiting the University of Oregon and gave a talk last night with Ambassador Kathleen Stephens, the former US Ambassador to South Korea. The questions and comments we got from the audience are windows into how people see things and how they understand the issues. There’s a fair amount of demonization happening. So, people say things like North Korea is not trustworthy and ask why we are negotiating with them. We hear that a lot. But that kind of thinking prevents any kind of progress. The work that KPI is doing—providing analysis and education—is what is necessary. I wish the education around and views on US-North Korea relations could be more balanced. As of now, it’s very one-sided. They’re bad and we’re good. The truth is we’ve done a lot of things to create a level of paranoia for the North Koreans. I think most Americans just don’t understand how complicit we are in all of this. That’s a big concern. 

[Haeyoung Kim] What can we expect to see from you and your work in the foreseeable future, Dr. Park? 

[Dr. Kee Park] I'm a global health practitioner working in the field of global surgery at Harvard Medical School. I feel fortunate to have found the intersection between North Korea and global surgery, which allows me to engage more with policymakers and conduct research that would be more focused on the needs of the population. I would like to continue studying the health of North Korean people and the impact of geopolitics on health. 

My immediate plans are to start a health policy project on North Korea within the medical school, which would enlarge the work I’ve been doing. The project is going to sit within the Global Health Department at Harvard Medical School. For now, we’re thinking of calling it the Korea Health Policy Project. We’re going to bring in researchers and form a faculty, and keep looking at the current standoff on the Korean peninsula from the global health standpoint. How does the failure to achieve peace impact the health of the North Korean people? What does that mean as far as what we should be standing for and what positions we should be taking as health advocates? Peace is a prerequisite to health, and in no place is that clearer than in North Korea. 



This article is jointly published with the Korea Policy Institute

Kee B. Park, MD, MPH, is a lecturer on Global Health and Social Medicine and Director of the Korea Health Policy Project at Harvard Medical School. He also serves as Director of the North Korea Programs at the Korean American Medical Association, and has led over 20 delegations to North Korea since 2007 to work alongside and collaborate with North Korean doctors in the DPRK. Dr. Park obtained his medical degree from Rutgers University, trained in neurosurgery at the Temple University Hospital in Philadelphia, Pennsylvania, and earned a Master of Public Health from Harvard’s T.H. Chan School of Public Health.

 

Haeyoung Kim is a Korea Policy Institute (KPI) Executive Board Member.