North Korea—the case for health diplomacy, by Richard Horton

The Lancet – President Trump’s August 30 tweet was blunt: “Talking is not the answer!” He was referring to North Korea (the Democratic People’s Republic of Korea, DPRK). “The US has been talking to North Korea, and paying them extortion money, for 25 years”, he wrote. Meanwhile, as punishment for North Korea’s firing of a missile over Japan’s Hokkaido island, UK Prime Minister Theresa May threatened further economic sanctions to end the DPRK’s nuclear provocations. The goal of western nations, united with China and Russia on the UN Security Council, is to squeeze Pyongyang to such an extent that the regime capitulates, even collapses. On August 5, the Security Council passed Resolution 2371, the effect of which would be to cut a third of the DPRK’s exports in coal, iron, lead, and seafood—worth around US$1 billion. Further sanctions would likely target textiles, oil, and banking. This strategy of progressive strangulation is mistaken politically and inhuman morally. Punishing Kim Jong-un is one thing. Collectively punishing DPRK’s 25 million people is quite another. The DPRK is not only a political entity. It is also a society of human beings. It is easy for western leaders to demonise a nation-state. But it is ethically unacceptable to demonise a population that is already suffering.

The global health community has in place a comprehensive strategy for health improvement in the DPRK. WHO has, for example, a country cooperation strategy with North Korea extending from 2014 to 2019. This strategy acknowledges the “significant public health challenges” faced by the DPRK. Responsibility for these challenges rests “in large part with external geopolitical factors”—the collapse of the Soviet Union and economic sanctions imposed by the international community. The result of these political forces has been declines in nutritional status and outbreaks of infectious disease. WHO points to improvements in childhood immunisation and access to health services for those living with malaria and tuberculosis. The Global Burden of Disease estimates improvements in maternal mortality rates—from 101 maternal deaths per 100 000 livebirths in 1990 to 73 deaths per 100 000 livebirths in 2015. Life expectancy for women in 2005 was 72·6 years, and in 2015, 74·9 years (for men, 67·5 years and 68·9 years in 2005 and 2015, respectively). As in all countries today, non-communicable diseases “now represent the primary determinant of morbidity and mortality”. WHO points to critical shortages in health workers, essential medicines, and health financing. “Geopolitical factors” explain low levels of development assistance. The Global Fund and GAVI provide vital support. And, in collaboration with the European Union and non-governmental organisations, important partnerships have supported national efforts to improve health outcomes in the face of growing political constraints. There are important gaps: access to reproductive health care, food insecurity, vulnerability to national disasters, air pollution, tobacco control, lack of access to life-saving commodities, and poor hospital referral networks. Although the political context is extremely adverse, the health strategy in place to support the DPRK is strong, even impressive. This positive narrative is entirely absent from current public discussions about the DPRK. The persistent failure to balance issues of global defence security with those of national human security is a catastrophic betrayal of the people of the DPRK. What more could be done?

First, we must acknowledge the pain and humiliation faced daily by many millions of North Koreans. An extraordinary document was published this year—The Accusation (Serpent’s Tail, 2017). The author isn’t known, although he has been given the name Bandi. What is known is that his text was smuggled out of the DPRK and first published in 2014. The publishers call it “an important work of the North Korean samizdat literature and a unique portrayal of life under a totalitarian dictatorship”. The stories of tyranny, persecution, and torment are harrowing. All the more reason to avoid adding further harm to the fractured lives of the DPRK’s afflicted people. Second, the health community can be a powerful diplomatic tool to advance health and wellbeing through politically neutral collaborations. Academic and health partnerships can be a compelling means to humanise a nation in desperate need of our embrace. Talking is indeed the answer. And medicine can be one route for such humanitarian engagement and discourse.

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