On June 9, 2016, North Korean leader Kim Jong-un was captured smoking on camera, the first photo taken of him holding a cigarette in two months. While Kim is known to be a heavy smoker much like his father and grandfather, the photo attracted international attention as North Korea is in the midst of an aggressive anti-smoking campaign.
North Korea’s anti-smoking efforts are just one facet of a broader public health campaign launched by Kim Jong-un. The DPRK regime has also sought to curb infant mortality rates in a bid to close the 12-year gap in life expectancy with South Korea. While these efforts have achieved some successes, positive momentum gained from these efforts could be flat-lined by North Korea’s increasing international isolation and the egregious corruption that still plagues its health care system.
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The principal focus and most public aspect of North Korea’s public health campaign has been the reduction of tobacco consumption, especially amongst men. North Korea’s smoking rates have been consistently amongst the highest in the Asia-Pacific region. NK News reports estimate that 90 percent of men in the DPRK smoked during the 1990s, a trend that did not appreciably change during the years of famine.
North Korea’s efforts to curb smoking began in 2000, when Kim Jong-il allegedly quit the habit on the orders of his doctors. Kim Jong-il made a public statement describing smoking cigarettes as equivalent to “aiming a gun at your heart.” Amidst speculation that his health was declining, Kim Jong-il ordered a ban on smoking in all public places visited by the “Dear Leader” in 2007.
These efforts only had a limited effect on tobacco consumption in North Korea. In 2012, 54 percent of North Korean men smoked, a total far higher than the 30 percent target set by the DPRK regime for the 100th anniversary of Kim Il-song’s birth. Yet efforts to crack down on tobacco consumption have become increasingly strident in their tone. In a 40- minute public health documentary on North Korean state television released in May 2016, women chastised men who smoke for their “senselessness” and “for their lack of a sound mind.”
The prominent depictions of women in North Korean anti-smoking commercials differ from most DPRK radio broadcasts. But the idea that the cultural taboo against female smoking (according to NK News, only elderly women in rural areas showed statistically significant levels of tobacco consumption) could be extended toward men seems to have little effect on deterring the habit. Smoking amongst men has effectively become a subtle form of passive resistance to the regime and appears to be a trend that will ebb gradually.
The second dimension of North Korea’s public health campaign, which has been more appreciably successful, is the DPRK’s attempt to reduce infant mortality rates. A UN report released on June 1 showed that North Korea’s mortality rate for children under age 5 has declined from 26.7 to 20 per 1,000 since 2008. Corresponding mortality rates for infants under age 1 fell from 19.3 to 14.2 per 1,000.
These declines have been attributed to North Korea’s adoption of telemedicine in 2011 and the greater cooperation between regional hospitals on medical technology. The extent of the improvements reported in the UN have been challenged by 2016 World Bank data, which showed little appreciable improvement since Kim Jong-il’s death. But the declines registered are in line with the World Health Organization’s (WHO) depiction of North Korea’s health care system.
In response to scathingly critical reports from Amnesty International in 2009, the WHO in 2010 contended that North Korea does not have a shortage of doctors and that hospital care had improved significantly since the 1990s. These recent UN statistics appear to support the WHO’s assertions, despite severe ongoing problems with malnutrition and corruption within the health care system.
Potential Obstacles to Durable Health Care Improvements in North Korea
Despite Kim Jong-un’s recent public health campaign, the prospect of durable improvements in North Korea’s health care system remains limited for three reasons. The first is North Korea’s worsening international isolation and the corresponding intensification of the UN sanctions regime. Ricky Choi, a U.S. doctor and author of a major report on North Korea’s health care system told The Guardian in 2014 that sanctions had exacerbated the DPRK’s health care crisis, as they occurred in tandem with “financial collapse, the shock of the Soviet Union’s collapse, and meteorological disasters.”
Sanctions have also made it impossible for DPRK hospitals to import vital equipment and medicines necessary to improve health care. North Korean defectors in China have reported widespread use of self-medication, the use of methamphetamines in place of legal drugs, and amputations occurring without anesthesia.
The second problem is the North Korean government’s chronic under-funding of the DPRK’s health care system and egregious corruption within the health care bureaucracy. Despite Kim Jong-un’s rhetorical emphasis on good health being a vital component of the success of socialism, North Korea spends just 6 percent of its GDP on its health system. This is a significantly lower level than in many other developing countries. This under-funding can be attributed largely to the military-first policy. It neutralizes the structural advantages North Korea possesses due to its higher number of doctors per capita than many other countries of its income level.
Corruption within North Korea’s health care system has corresponded with drastic regional inequalities. The standards of medical care reported in Pyongyang, where elites receive treatment, differ strikingly from hospitals in the rural areas, which are largely cut off from international observers. North Korean pharmaceutical companies have also been complicit in not producing necessary drugs, preferring instead to sell counterfeit products for black market revenues.
This problem was noted in a 2005 Japanese report detailing how North Korean pharmaceutical companies manufactured fake Viagra in Chongjin to sell to Hong Kong, China, the Middle East, and Southeast Asia. Prosecutions for these forms of corruption are intermittent and often occur at the behest of foreign countries, like the 2004 arrest of a man carrying 4,000 counterfeit Viagra pills in Seoul.
The third issue plaguing the North Korean health care system is a lack of transparency. Purported achievements in health policy have often been exaggerated in North Korean propaganda. Outlandish statements made by the North Korean state media, like the DPRK’s development of the Kumdang No.2 Vaccine against HIV/AIDS, also compromise the credibility of any advances declared by North Korean officials.
As health care is extensively politicized and linked to improving the international image of the regime, the most problematic public health problems, like the DPRK’s ongoing tuberculosis epidemic (a disease which kills 2,500 North Koreans every year), get little domestic attention.
Perhaps the biggest threat to North Korean public health, malnutrition, which rose by 38 percent in 2014 in response to drought and declining food harvests, also remains a taboo subject in Pyongyang that is routinely obscured. Therefore, it is erroneous to extrapolate from achievements in targeted areas like anti-smoking or infant mortality reduction to the entire health care system.
While North Korea’s public health campaign under Kim Jong-un is a belated attempt to improve lifestyle factors and medical conditions after decades of pledges by the regime, these efforts’ long-term prospects of success and their extension to resolving other health issues remain limited. The DPRK’s acute international isolation and the extensive politicization of the health care system makes genuine reform an uphill battle regardless of pressure exerted by international institutions and human rights watchdogs.
Samuel Ramani is an MPhil student in Russian and East European Studies at St. Antony’s College, University of Oxford. He is also a journalist who contributes regularly to the Washington Post, Huffington Post, and Kyiv Post amongst others. He can be followed on Facebook at Samuel Ramani and on Twitter at samramani2.