North Korea continues to deny that it is affected by the coronavirus. Yet all indications are that there is an outbreak in the North, though the extent of it is unknown. Such an outbreak can have severe consequences for South Korea, the ROK-U.S. alliance, and the region that few dare to consider: North Korean internal instability that could lead to regime collapse.

North Korea is the least-equipped country in the world to deal with coronavirus. Last week, at a ground-breaking ceremony for a new Pyongyang General Hospital scheduled for completion by October, Kim Jong Un himself admitted that North Korea lacks modern medical facilities and demanded improvements. Although he did not explicitly mention the coronavirus, Kim is likely wary of its potential impact on his regime.

To be sure, the Kim regime has insisted it has everything under control. To mitigate a potential outbreak, North Korea has tried to close its borders and suspend trade. It has also heavily restricted the domestic movement of its citizens.

But the United Nations, ROK/US Combined Forces Command, and other organizations are skeptical. Based on the spread of the virus globally and North Korea’s precarious geographic positioning between South Korea and China, which have both experienced high numbers of coronavirus infections, it is logical to assume the virus has spread there.

General Robert Abrams, the highest ranking U.S. military officer in Korea, stated he is “fairly certain” of a northern outbreak based on reports that the North Korean military was under a 30 day lockdown. Daily NK, a digital news publication organized by North Korean escapees, has reported that as many as 200 North Korean soldiers have died as a result of the virus.

Kim’s sister, Kim Yo Jong, revealed that the North Korean leader had received a letter from President Trump offering help. Similarly, South Korea and the UN have offered support to the Korean people. Yet it is highly unlikely the regime will ask for or accept substantial aid. Concerned more about projecting an image of strength than the welfare of its people, only when catastrophic conditions occur inside North Korea would the regime accept help.

If it ever approved foreign assistance, the regime would likely accept only forms of help it can control: either direct cash payments or food and aid provided directly to the regime. Little or none of it would get to the intended recipients. Unless the regime allows transparency so independent monitors can ensure aid goes to those most in need, the U.S. and the international community should only provide aid with such verification protocols set and ensured as the innocent North Korean people should not suffer for its government’s transgressions. If not, the world risks providing aid that only helps the regime elite without alleviating the suffering of its vulnerable people.

While a pandemic’s direct impact on the lives of the innocent Korean people in the North will be devastating, it is the effect on the military – and consequently on Kim’s decision-making – that creates strategic risks for the U.S./ROK alliance. Failure to curb a widespread epidemic could undermine internal stability, thereby forcing the regime into a crisis decision-making mode. In the short term, Kim would likely engage in provocations to demonstrate that he firmly maintains control. North Korea already conducted three separate short-range missile tests over the first three weeks of March, likely part of the North Korean military’s winter training cycle. Kim in turn may direct continued missile and rocket testing.

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Such provocations could lead to miscalculation and escalation on both sides, which could bring devastating consequences. It is also likely that cyber attacks will increase as a means both to steal funds and to create chaos and distraction around the world. Unidentified hackers already attacked the U.S. Department of Health and Human Services with a distributed denial of service (DDoS) attack to disrupt Washington’s broader coronavirus response efforts. This fits a pattern of previous North Korean attacks against medical systems.

Additional reports found disinformation being dispersed to sow chaos among the American public. While the U.S has not attributed this attack to anyone, Washington should be on guard for attacks on public health systems, because even if there is no outbreak in the North, it may seize the current opportunity to employ what Kim has described as its “all-purpose sword” of cyber warfare.

One of the true unknowns is whether the coronavirus crisis will create the conditions for regime collapse. During contingency planning efforts in the 1990s, planners defined collapse as the loss of the ability of the Korean Workers Party to govern the entire territory of the north from Pyongyang, combined with the loss of coherency of the military and of its support for the regime.

Expert analysts studying Korea anticipate a collapse would stir a series of far-reaching catastrophes on the peninsula that has regional if not global repercussions. These may include a humanitarian disaster – far surpassing the Arduous March of the Famine of 1994-1996 (estimated deaths between 600,000 and 1 million)– that could result in massive refugee movements north into China, south across the DMZ into the ROK, and via the East Sea to Japan. The situation would create extreme danger, with the potential loss of control of nuclear, biological, and chemical weapons of mass destruction. Competition for resources among military units with no central party control may also lead to conflict over scarce resources, which could escalate into civil war.

There have been predictions over the past three decades that North Korea would experience instability and regime collapse, particularly after the famine in the mid-1990s. However, the regime and the Korean people in the north have proven very resilient. Most importantly, the regime received billions of dollars in aid from South Korea from 1997 through 2007 that not only contributed to its survival but also to the funding of its first nuclear test in 2006. This time may be different. The coronavirus could spread too rapidly and overwhelm the North Korean system, and the regime is unlikely to receive the amount of cash aid it did two decades ago.

All of these scenarios demand that policy makers, strategists, and military planners be on guard for indicators of North Korean instability. They must prepare for the very real possibility that contingency plans may have to be executed by the alliance. The ROK/U.S. Combined Forces Command in particular must now review contingency plans for the full range of threats.

David Maxwell, a 30-year veteran of the U.S. Army and a retired Special Forces colonel, is a senior fellow at the Foundation for Defense of Democracies (FDD), where Mathew Ha is a research analyst. Both contribute to FDD’s Center on Military and Political Power (CMPP). For more analysis from David, Mathew, and CMPP, please subscribe HERE. Follow David and Mathew on Twitter @davidmaxwell161 and @matjunsuk. Follow FDD on Twitter @FDD and @FDD_CMPP. FDD is a Washington, DC-based, nonpartisan research institute focusing on national security and foreign policy.

Editor’s note: This is an Op-Ed and as such, the opinions expressed are those of the author. If you would like to respond, or have an editorial of your own you would like to submit, please contact Military Times managing editor Howard Altman, haltman@militarytimes.com.