North Korea’s healthcare system is as mysterious as the country itself. That makes a stark contrast to with its boisterous neighbor in the south, which Bloomberg said had the fourth most efficient healthcare system out of relatively developed 55 nations in 2016.

Despite their silence, many allegations and rumors have been circulating about the appalling state facing North Korea currently. But the lack of validity and reliability of its health data is the largest obstacle to understanding the true situations of the hermit kingdom.

To take a deeper look into the crumbling healthcare system of North Korea and the possibility of preparing for the unification of two countries, Korea Biomedical Review (KBR) met with two experts Wednesday -- Professor Jeon Woo-taek_전우택 of the Department of Medical Education at Yonsei University College of Medicine, and Professor Kim So-yoon_김소윤 of the Department of Medical Law and Ethics at the same college.

Professor Jeon, also chairman of the Association of Healthcare for Korean Unification, has traveled to North Korea twice to monitor the supplies of food and medicine. Professor Kim is working with World Health Organization (WHO) Collaborating Centre for Health Law and Bioethics.

Yonsei University Professors Jeon Woo-taek (right) and Kim So-yoon express their desire for a unified Korean healthcare system, during an interview with Korea Biomedical Review Wednesday.

KBR: Please briefly explain North Korea’s healthcare.

Jeon: A lot of people don’t know this, but North Korea had an efficient health system – until the 1970s, a state-funded and state-managed public health system based on the Soviet model. It boasted declining infant mortality rate, high vaccination rate, and drop in mortality from infectious diseases.

Since the 1990s, however, the system has been under a significant stress from which it has yet to recover. The fall of the Soviet system and China’s transit to the capitalist system led to the loss of its favorable trade relationship. Added by frequent droughts, floods, and typhoons, widespread famine and malnutrition attacked the communist country, along with the shortages of medicines.

Kim: In theory, hospitals and clinics in communist and socialist countries are filled with public officers decently paid by the government. In reality, however, doctors are not paid properly, and their hospital buildings are in deplorable condition. There is a lack of financial resources, medicines and vaccines, power and heat, a limited supply of clean water, and food.

Allegedly, shortage of electricity is said to be responsible for the decline of the North’s pharmaceutical industry, forcing it to import medicine which had been produced domestically. But even import does not guarantee drugs will be available in hospitals and clinics. What usually happens is that doctors prescribe medicine, but patients have to search for it in the market.

This poses certain risks such as inadequate knowledge of side effects, as doctors cannot monitor them, and many of the available drugs are counterfeits from China. Increasingly, the general public is not turning to hospitals for treatment when they are sick, but rather stay at home and to have their family members nurse them back to health. This increases the chance of spreading infections to their families.

KBR: What are the requirements to become a doctor in North Korea?

Kim: Because there are only 12 medical schools in the country, the demand is very high, and competition is fierce, mostly among high-quality students with good family backgrounds. They study for five to six years and undergo a practicing period of six months, but there is no formal residency training programs, no medical specialists, and no official government licenses.

When medical students graduate, they are assigned to a department by the government although they only studied to be primary doctors, and gain experience there. Health practices and standards are outdated, with most hospital directors trained in medicine but not in management and supervision.

KBR: How many patients does a North Korean doctor need to take care of on average?

Jeon: Forming the foundation of their health care system is what the government calls “ho (household) doctor system” where one doctor is responsible for the primary care of around 130 families in one district. Unlike South Korea, where having a career as a physician means financial and social prestige, the medical doctor in a communist country is not an attractive job. One defector that we interviewed suggested that the job would be more in demand if Koreas are unified.

KBR: What does N. Korea need most among drugs, blood supplies, medical equipment, and surgical tools?

Jeon: While all these that you just listed are very limited, I believe that medicine is the most urgent. Most drugs in the market are smuggled from China, whose components no one can identify. To replace modern medicine, “dongeuihak” (eastern medicine) is used and is highly esteemed. This included ginseng, deer’s placenta, and a mixture of herbs. They also practice “ddeum” or moxibustion - a form of heat therapy by burning herbs and grasses on the skin, along with acupuncture.

KBR: What are some of the most common diseases in North Korea?

Kim: Infectious diseases are most common such as tuberculosis, hepatitis, and malaria. When patients require surgery, the inadequate sterilization of equipment used in operations leads to diseases transmission and post-secondary infections. Although there are no available statistics, we suspect that these practices contribute to hepatitis B transmission.

Jeon: Non-communicable diseases, such as heart attacks, asthma, and cancer, are also steadily increasing. What’s interesting is that although North Korea is an underdeveloped country, it’s different from Africa because they used to control infectious diseases very well in the past. In African nations, their conditions mostly contain infectious diseases while Western countries mainly have non-communicable diseases. But because North Korea has both, we called this “Bio-modal pattern.”

KBR: Does the North Korean public receive disease prevention education programs?

Jeon: They are crucial for North Koreans to prevent diseases. In the 1960s and ’70s, they had an excellent education system on personal hygiene. With shortages of clean water and healthy food, however, it’s inevitable they are contaminated.

KBR: On humanitarian grounds, South Korea made many donations such as drugs and medical equipment before. Under President Moon Jae-in, the South plans to resume contributions to the North. How should the government and private sector, including the Korean Medical Association (KMA), divide their roles in this project?

Kim: South Korea, China, and the United States are largest donors of humanitarian assistance to North Korea. Although President Moon wants to help North Korea’s healthcare, it’s not that simple. An example was seen in 2008 when the U.S. pledged to supply 500,000 metric tons of food aid to North Korea as part of a denuclearization deal. However, only about a third of the aid was delivered before disagreements between the two governments prematurely ended the support program.

According to the Eugene Bell Foundation last month, however, it released 1.9 billion won ($1.7 million) worth of tuberculosis drugs and ward materials. The approval of the export of the materials to North Korea is the first since President Moon took office.

Jeon: Humanitarian assistance is needed, but if their nuclear weapons program is still under way, it makes the situation worse. The KMA remains silent because it does not want to get involved politically and most have little interest. However, some are very eager, and the Association of Healthcare for Korean Unification_{통일보건의료학회} has already been preparing for the merger of South and North’s healthcare system.

KBR: How should the health care system be ready for the unification?

Kim: It depends on how the unification will unfold in political terms. Can people go freely to North Korea or the South? Will there be a separate government, or will the two governments merge? But we do hope that unification people become a reality in 20 years, although a defector said it wouldn't happen within 100 years.

Jeon: There are two steps we need to overcome on a basic level. Finance is one because the health system requires an enormous amount of money, for which North Korea cannot pay. The South Korean government should help, but at the same time, money is not the only problem. Socially, South Korean civilians need to understand and agree to pay for the expense of North Korean people as well. We need to agree on prepayment; when North Korea’s economic status rises, they can return the money back to South Korea.

The second step is education and retraining of North Korean doctors. The number of physicians and their medical steps are sufficient, but their education level is shallow. We should prepare how they need to be re-educated. When the training begins, we should provide them with efficient and flexible programs.

KBR: Will South Korean recognize North Korea’s medical licenses?

Kim: South Korea and North Korea have different procedures for acquiring medical licenses. When North Korean medical students pass the medical school examination, they are qualified as a doctor, but there is no national exam to obtain a doctoral license like South Korea. There will be a lot of controversy about the licensing standards after the unification because exam subjects, evaluation methods, and acceptance criteria are different.

To obtain a license to conduct medical activities in South Korea, North Korean defectors must go through the certification process and pass the qualification examination. According to the Law Concerning the Protection and Settlement Support of North Korean Refugees, North Korean doctors’ academic ability and qualifications are recognized in South Korea, but most of them cannot be confirmed as they do not have the documents.

KBR: Will there be a system where North Korean doctors can work in the international medical field?

Jeon: There is already a system where North Koreans work abroad. It does sound silly; why would North Korea allow their doctors to work out of their country when their system is already collapsing as it is? In African nations, however, North Korean doctors are high in demand because their salaries are very cheap. For example, Russians doctors get $300 a month to work in Africa, but North Korean doctors can work for $100, and 80 percent of their salaries go back to the North Korean government. That is the reason why the government is almost eagerly sending their doctors abroad; they can make money while gaining experiences. When South and North Korea unify into one, changes must follow.

connie@docdocdoc.co.kr

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