Drivers of health transition in the DPRK
Authors: Ri Hak Chol, Ahmed Madar, Jon Klokk Slettedal, Kjersti Bergsmark Bjertness, Johanne Sundby, Espen Bjertness
Journal: The Lancet Planetary Health (2019)

The health situation and the drivers of the health transition in the Democratic People's Republic of Korea (DPRK or North Korea) after the Korean War (1950–53) have mainly been discussed in international literature by scientists living outside the country. The current health challenges in North Korea range from chronic undernutrition and tuberculosis to non-communicable diseases.1Ministry of Public Health, North KoreaAnnual Health Report, DPR Korea 2017. Ministry of Public Health, Pyongyang2018Google Scholar, 2Country profile North Korea.http://www.healthdata.org/north-koreaDate: 2018Date accessed: May 14, 2018Google Scholar Reports from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017,3GBD 2017 Mortality CollaboratorsGlobal, regional, and national age-sex-specific mortality and life expectancy, 1950–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 1684-1735Summary Full Text Full Text PDF PubMed Scopus (522) Google Scholar indicate no change in life expectancy from 1990 (71·8 years) to 2017, with a drop in 1995 (62·9 years) to 2000 (62·1 years), and a modest increase of 1·7 years from 2005 (70·3 years) to 2017 (72·0 years). The 2017 annual health report1Ministry of Public Health, North KoreaAnnual Health Report, DPR Korea 2017. Ministry of Public Health, Pyongyang2018Google Scholar shows a similar pattern in life expectancy: 74·5 years at the end of the 1980s, a drop in the mid-1990s, an increase to 70·3 years in 2010, reaching 72·7 years in 2015. The most common negative drivers and probable causes of the trends in life expectancy discussed in the international literature include the collapse of the Soviet Union in 1991, natural disasters in the 1990s,4Bjertness E Madar AA North Korea: a challenge for global solidarity.Lancet. 2014; 383: 1381-1382Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar and economic sanctions. These three factors have negatively affected North Korea's socioeconomic progress and public health,1Ministry of Public Health, North KoreaAnnual Health Report, DPR Korea 2017. Ministry of Public Health, Pyongyang2018Google Scholar and together have caused damage to achievements in health-care and welfare services in the form of malnutrition, incidence of communicable diseases, and high mortality rates, which were inconceivable in the past.1Ministry of Public Health, North KoreaAnnual Health Report, DPR Korea 2017. Ministry of Public Health, Pyongyang2018Google Scholar Economic sanctions against North Korea have been imposed by the USA since the 1950s and by the UN and EU over the past decade,5Sanctions against North Korea.https://en.wikipedia.org/wiki/Sanctions_against_North_KoreaDate accessed: September 3, 2018Google Scholar with strict sanctions implemented in 2016 and 2017, respectively. In general, strict sanctions with large economic effects can have public health consequences, including on the availability of food, clean water, and medicines; however, when the economic effect is minor, public health is largely unaffected.6Allen SH Lektzian DJ Economic sanctions: a blunt instrument?.J Peace Res. 2013; 50: 121-135Crossref Scopus (76) Google Scholar The exact effects of economic sanctions on public health in North Korea are difficult to elucidate, but they cannot be tolerated if they negatively affect the wellbeing of the people. The sanctions are likely to have affected population health, and even more so in the past 2 years. For example, import restrictions on medical equipment and chemical compounds to produce medicines have led to insufficient supplies of antibiotics (both intravenous and tablet form), not only in rural hospitals, but also in the best-equipped hospitals in Pyongyang. Insufficient supply of modern medicines has prompted further development of traditional medicine (ie, Koryo medicine),7Lim B Park J Han C Attempts to utilize and integrate traditional medicine in North Korea.J Alt Complement Med. 2009; 15: 217023Crossref Scopus (10) Google Scholar especially in the past 2–3 years. In June, 2018, the Global Fund ended the tuberculosis and malaria programmes,8Burki T North Korea and the Global Fund.Lancet Infect Dis. 2018; 18: 501Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar which might pose a future burden to health in North Korea. Additionally, the 45% reduction in aid disbursements from development assistance committee countries from 2012 to 2017, might affect the life expectancy, health, and wellbeing of people in North Korea.9Organisation for Economic Co-operation and DevelopmentAid (ODA) disbursements to countries and regions [DAC2a].https://stats.oecd.org/Index.aspx?datasetcode=TABLE2ADate accessed: February 4, 2019Google Scholar Examples of positive drivers of the health transition in North Korea are improved vaccination coverage, advances in medical technology (including the adoption of telemedicine in 2010), and long-distance online medical training between universities and hospitals. North Korea has put forward several economic reforms, including the Chollima movement in the late 1950s, to rebuild North Korea's economy after the Korean War, and the Mallima movement in 2017, which aimed to encourage faster economic transition. Despite the severe sanctions, the socioeconomy has developed, especially in the large cities, overcoming the economic crisis in the 1990s. The gross domestic product per capita increased from US$463 in 2000 to $1053 in 2014,1Ministry of Public Health, North KoreaAnnual Health Report, DPR Korea 2017. Ministry of Public Health, Pyongyang2018Google Scholar which is somewhat higher than estimates from the UN.10UN Statistics DivisionNational accounts estimates of main aggregates.http://data.un.org/Data.aspx?d=SNAAMA&f=grID%3A101%3BcurrID%3AUSD%3BpcFlag%3A1Date accessed: February 4, 2019Google Scholar At the core of the public health policy in North Korea is the adoption of preventive medicine in health activities, and strengthening of the universal free medical care system. The government guarantees, by both policy and law, to protect and care for the lives and health of people in North Korea,1Ministry of Public Health, North KoreaAnnual Health Report, DPR Korea 2017. Ministry of Public Health, Pyongyang2018Google Scholar and states that health is a human right. For example, the lives and health of mothers and children will be protected and promoted through maternity leave (240 days in 2015), shorter working hours for mothers with several children, and scaling up the network of maternity hospitals, nurseries, and kindergartens.1Ministry of Public Health, North KoreaAnnual Health Report, DPR Korea 2017. Ministry of Public Health, Pyongyang2018Google Scholar North Korea is actively trying to promote cooperation and exchange of both knowledge and people with other countries in public health. An example is the cooperation, established in 2010, between Pyongyang Medical College, Kim Il Sung University in North Korea and the University of Oslo in Norway. In an effort to become a leading university, Pyongyang Medical College acknowledges that it needs to contribute to the international scientific literature, which is scarce at present. The University of Oslo aims to assist Pyongyang Medical College to build capacity in international scientific writing, and a bilateral exchange of staff and students. The University of Oslo is offering seats at their international summer school to staff of Pyongyang Medical College to build competence in international community health, which might further strengthen the collaboration between Norway and North Korea, and ultimately improve population health. Kim Il Sung University is interested in establishing international cooperation in public health, clinical medicine, and basic medical science. Provision of e-learning resources and medical journals sent on a regular basis by mail and subscriptions from international universities and research journals are welcomed. Medical training programmes in both North Korea and abroad that include international partnerships might help to advance population health and wellbeing in North Korea and, in the end, all people globally. Such cooperation is supported by Richard Horton in the Lancet,11Horton R Offline: North Korea—the case for health diplomacy.Lancet. 2017; 390: 1016Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar suggesting that the health community can be a powerful diplomatic tool to advance health and wellbeing in North Korea through partnerships. University cooperation is a public health imperative, and can be done to foster global health solidarity. In light of the fifth North–South summit and talk between Comrade Kim Jong Un, chairman of the State Affairs Commission of North Korea, and Moon Jae-in, South Korean president, and meetings between North Korea and USA, the time to establish international and national academic cooperation is now.12Normile D Korean thaw raises hopes for scientific cooperation.Science. 2018; 360: 475-476Crossref PubMed Scopus (2) Google Scholar The 2030 Agenda for Sustainable Development promises to leave no one behind13UN General AssemblyTransforming our world: the 2030 Agenda for Sustainable Development. Resolution adopted by the General Assembly on 25 September 2015.http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=EDate accessed: May 18, 2018Google Scholar—a pledge that should include both vulnerable populations and whole countries. The global community should aim to keep the promise of the Sustainable Development Goals to ensure healthy lives and promote wellbeing for all14UN Sustainable Development GoalsTransforming our world: the 2030 Agenda for Sustainable Development.https://sustainabledevelopment.un.org/post2015/transformingourworldDate accessed: February 4, 2019Google Scholar in a "just, equitable, tolerant, open, and socially inclusive world".13UN General AssemblyTransforming our world: the 2030 Agenda for Sustainable Development. Resolution adopted by the General Assembly on 25 September 2015.http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=EDate accessed: May 18, 2018Google Scholar We declare no competing interests.