Questions over the future of denuclearisation and economic sanctions dominate the build-up to this week’s summit between the United States and North Korea. But what’s missing is a focus on a key issue affecting ordinary North Koreans: the country’s silent healthcare crisis.

North Korean leader Kim Jong-un and US President Donald Trump are scheduled to begin talks on 27 February in Hanoi, Vietnam – the second encounter between the two men after last June’s summit in Singapore, which sparked reams of analysis but few tangible results.

Speculation abounds over what might materialise this time: concessions on sanctions, a path toward denuclearisation, perhaps even – if comments from South Korean officials this week are to be believed – an official peace declaration.

As the two leaders meet, however, everyday North Koreans are struggling with widespread malnutrition and food insecurity. The UN says many North Koreans have difficulty accessing basic services, while more than 40 percent of the country’s population need some form of humanitarian aid.

Health indicators have improved in the two decades since the country’s 1990s famine – during which hundreds of thousands of people starved to death. But there are still major problems. Levels of malnutrition, maternal health, and tuberculosis are worrying enough, but a lack of accurate data on HIV/AIDS and hepatitis B presents new cause for alarm.

Malnutrition: The common denominator

North Korea is frequently portrayed as an unknowable, impenetrable land. However, a substantial amount of data on health indicators is readily available. While it must be treated with caution – malnutrition figures, for example, don’t include political prisoners languishing in camps – the data can be useful for showing longer-term trends.

Undernourishment is a common denominator for many of the health problems afflicting North Koreans.

When it comes to the effects of malnutrition, the data shows an improvement in the two decades since the famine ended – but also clear indications of a continuing problem. In 1998, a UNICEF survey found evidence of child stunting – when a child’s height falls considerably below what would be expected at that age. About 62 percent of children younger than seven years of age showed stunted growth, while 60 percent were considered underweight. In 2017, UNICEF’s Multiple Indicator Cluster Survey – drawn from household survey data – reported that roughly 19 percent of children were stunted, while about 9.3 percent were underweight.

This is clearly an improvement. But one in five children are still considered stunted. The children in the 1998 survey are now in their 20s, many likely with children of their own. Today, the World Food Programme estimates that 10.9 million people are undernourished – about 43 percent of the population. And undernourishment is a common denominator for many of the health problems afflicting North Koreans.

Undernourishment in pregnant women

Indicators gauging maternal health in North Korea vary widely. The maternal mortality ratio estimates the proportion of women who die during pregnancy – essentially the risk associated with pregnancy in a given country. World Bank data suggests the maternal mortality ratio in North Korea has fallen steadily since a peak in 1999. However, data from North Korea’s own Central Bureau of Statistics says the maternal mortality ratio has fluctuated and even risen in recent years: from 72 per 100,000 live births, to 62.7 in 2014, then a notable jump to 82 in 2015.

Even using the World Bank’s more optimistic figures, North Korea’s maternal mortality ratio still hasn’t reached pre-famine levels – estimated at 56 deaths per 100,000 live births in 1992. And it’s still far off the mark set by South Korea, where the ratio is 11.

Current indicators suggest cause for concern. According to UNICEF, nearly one in three women of reproductive age are undernourished, and nearly one in four are underweight. And the UN agency says it couldn’t distribute nutritional supplements to 95 percent of pregnant and lactating women during a nationwide child health campaign last year, due to funding shortfalls.

Tuberculosis trouble ahead

There is a funding crisis for tuberculosis treatment in North Korea, and the disease may be killing people at an increasing rate. World Health Organisation estimates for tuberculosis deaths in North Korea are on the rise: from a low of 42 deaths per 100,000 people in 2015, to 63 in 2017.

The Global Fund – the donor agency financing treatment for HIV, tuberculosis, and malaria around the world – pulled funding for tuberculosis and malaria programmes last year citing oversight concerns in North Korea’s ”unique operating environment”. The decision was met with worried opinion pieces, open letters, and pleas of concern from the medical community.

With the impact of sanctions and the Global Fund’s withdrawal, there are fears this upward trend may continue. In an open letter published in the British medical journal The Lancet, the director of the Korean American Medical Association, which works on tuberculosis treatment programmes in North Korea, warned that medicine rationing triggered by drugs shortages could fuel the ”rapid creation of drug-resistant TB strains”.

North Korea already struggles with multidrug-resistant tuberculosis, which cannot be cured with the two most powerful drugs usually used to treat TB. The WHO estimated there were 4,100 such cases in the country in 2017, but less than half of affected patients had started treatment.

The Eugene Bell Foundation is another prominent NGO working on tuberculosis in North Korea. However, the group says its 12 treatment centres for multidrug-resistant tuberculosis can only hold 1,500 patients combined, meaning many North Koreans are unable to access its programmes.

Misplaced HIV assumptions?

Malnutrition, maternal mortality, and tuberculosis are relatively well documented in North Korea, but much less is known about the prevalence of HIV/AIDS and hepatitis B. This is particularly concerning given the scarcity of medical infrastructure, accurate screening, and specialised doctors and medicines.

The prevalence of HIV is one of the least understood health issues in North Korea. The government has claimed there are no HIV cases in the entire country. But the situation is opaque at best, hidden by stigma and the government’s reluctance to acknowledge the issue let alone openly tackle it. UN agency reports from the late 1990s and early 2000s mirrored the government’s assumptions that the country’s long isolation, low (official) migration, low drug use, and conservative sexual attitudes made HIV and AIDS a non-issue.

Over time, however, UN reports suggest multiple factors that could lead to a growing vulnerability among North Koreans. Surveys and analyses – conducted by UN agencies on reproductive health between 2002 and 2012 – point to increasing vulnerabilities to HIV transmission particularly among women. Condom use is extremely low, while the quality of blood transfusion is often poor. These conditions are amplified in border regions and in disadvantaged remote areas.

UN agencies note that on North Korea’s northern border with China, drug use and prostitution are on the rise, as are cross-border mobility and trafficking. A 2014 study by the South Korean Ministry of Unification noted that HIV-testing facilities and materials have long been scarcely available in North Korea, which challenges past assumptions of a nearly HIV-free country. Rather than a lack of infections, what we see in North Korea may actually be insufficient testing and misplaced assumptions.

Healthcare not on the agenda

For North Koreans grappling with the long-term impacts of an inadequate health system, a peace agreement and an end to hostilities will not, on their own, bring an improvement to their lives.

Available health statistics do not point to a country with a “brighter future”, but to a nation that will need prolonged and extensive care.

To reverse the impacts of years of undernutrition, North Koreans need reliable and consistent treatment delivered through a robust and well-functioning health system. That will require significant commitment from both the North Korean government and the wary international community. Without adequate funding, access, and the increased capacity to cope with today’s health burdens – including the ones we don’t yet fully grasp – many ordinary North Koreans will continue to struggle to live a full and healthy life.

North Korea may be keen to see the end of punishing UN sanctions, and long-term American objectives ahead of this week’s summit are clear: “the complete, verifiable denuclearisation of the peninsula”.

Realistically, however, the available health statistics do not point to a country with a “brighter future”, as repeatedly promised by US officials, but to a nation that will need prolonged and extensive care.

(TOP PHOTO: North Koreans gather in Pyongyang on 16 February 2019. CREDIT: Ed Jones/AFP)

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The authors are researching a book about North Korea and international cooperation.