Kim’s letter carried more than a tinge of irony. North Korea, which is technically at war with the South, has reported no cases at all. By contrast, South Korea's high numbers of cases are likely the result of its aggressive testing for the virus in order to get the outbreak under control. But North Korea lacks the health care infrastructure and capacity to do the same with its own people, and is notoriously secretive about events inside the country, so it’s hard to know what it is really going on.
This has raised fears that its population of some 25 million is at risk, especially those in remote areas or suffering from preexisting health conditions.
North Korea has used the most restrictive set of measures in the world to contend with the coronavirus outbreak — a near-total closure of its borders starting in January, around the time when the virus appears to have begun to spread outside China. North Korea said it is actively monitoring some 7,000 people for signs of the virus, and because movement within the country is already restricted for ordinary people, it likely has the capacity to restrict their movements further to try to prevent the spread of the disease.
But health care experts familiar with the situation inside the secretive country say North Korea may lack the needed amount of diagnostic machines and specific kits to test people for symptoms, leaving it reliant on assistance from China, Russia and the World Health Organization (WHO). Many parts of its health care system, they say, are incredibly under-resourced and close to collapse, putting its people at risk.
North Korea is heavily dependent on China — which is by far its largest trading partner and most important diplomatic ally — for the health of its economy. Its border with China is porous, with migrants and merchants traveling back and forth regularly. Because commerce with China makes up more than 90% of North Korea’s total trade, encompassing everything from fuel to humanitarian aid, the North Korean economy is reliant on China for survival. This includes both legitimate trade and illicit commerce that is forbidden by international sanctions but carried out at the border without any oversight.
The virus originated in the city of Wuhan in China’s Hubei province, but China did not begin restricting people’s movements until weeks after cases were first reported — likely in December 2019. During that time, an unknown number of people would have crossed the border between China and North Korea unchecked. Cases of COVID-19, the disease caused by the novel coronavirus, are likely to have come from this border region with China.
“Despite the near-total closure of its borders — using the most restrictive set of measures we have seen anywhere — it is more likely than not that cases of COVID-19 are inside North Korea,” said Kee Park, director of the US-based Korea Health Policy Project, in an email.
North Korea said this week via state media that it had placed about 10,000 people in quarantine, but released about 40% because they did not show symptoms. Because there is no independent media in the country and information is tightly controlled by the government, it is impossible to verify these claims.
A mishmash of factors — including lack of investment, a dearth of technological expertise, and international sanctions that have made it difficult to purchase many modern medical technologies — means that North Korea’s health care system is likely deeply underprepared for a viral outbreak. Its population is also particularly vulnerable because of issues with health and nutrition in the countryside. The UN special rapporteur for human rights said this week that North Korea needs to allow medical and humanitarian specialists into the country because of problems with malnourishment.
While South Korea responded to the virus by testing more people per capita than anywhere else in the world, in practical terms there is no way that North Korea has the ability to carry out adequate levels of testing on its population. Health care in North Korea is ostensibly free, but it’s really only the elites who live in the capital city of Pyongyang who can access good care. Hospitals in other parts of the country lack basic amenities, often including electricity, making it difficult to test for the virus.
One problem is that medical professionals cannot diagnose the virus based on observing symptoms alone because early symptoms are similar to the common flu — fever and cough. Lab testing using samples of saliva is needed. Dr. Lee Myungken, a medical doctor who worked for a decade in North Korea on humanitarian aid and economic development projects, said it’s likely only Pyongyang houses the equipment required to carry out tests. It presents a particular quandary for North Korea, where new infections are likely to originate near the China border.
Because of the country’s underdeveloped road and rail networks, Lee said, it would be very difficult to bring samples back to Pyongyang for testing in time.
In a March 2 press conference, Michael Ryan, an executive director at the WHO, said the agency had been in touch with North Korea about its response to the coronavirus outbreak, and that they weren't aware of any cases at the time. Ryan said the WHO had sent equipment, supplies, and diagnostic equipment, subject to “release sanctions.” He said the WHO was “ready to both strengthen our country office and send teams as needed.” Other countries including Russia have offered test kits and other medical supplies to North Korea. But it’s difficult to say whether this would be sufficient to address any potential outbreak.
“The DPRK (Democratic People’s Republic of Korea) has obtained some testing kits of late from foreign countries, but this is likely to only allow a very small number of people to get accurate results,” said Chad O’Carroll, CEO of Korea Risk Group, adding it was “probably a smart idea” for North Korea to have shut its borders early.
“However, given that China–DPRK trade constitutes 90% of the country’s economic relationship — and there is significant movement of people over the border — it is likely the virus entered before the draconian border closure was imposed,” he added.
Lee said North Korea’s health care system relies in part on remittances sent back by doctors working abroad. Pyongyang sends doctors to work in various countries — mostly in the developing world that lack medical expertise — and uses their salaries to fund regional hospitals across North Korea. But many of those countries have sent these doctors back, Lee said, after a recent round of international sanctions on North Korea and any country that trades with it.
Lee cited contacts within the North Korean doctors program for this information but declined to share specifics about their identities, out of concern for their personal safety.
Beyond closing its borders, North Korea has taken other steps to contend with the viral outbreak. On Sunday it flew the staff of several diplomatic missions, as well as aid workers and business people, to Russia. The government has also postponed an annual film festival, originally slated for September, by a month, and called off the Pyongyang marathon, one of the few international tourism events that brings people from outside the country.
As with so much that happens in North Korea, it may be a long time before we find out what impact the coronavirus has had in the world's most secretive state.