Introduction

The global pressure campaign on North Korea continues to escalate as North Korea pushes the boundaries of provocation. In recent days, North Korea has tested a new long-range missile design, mobilized 500 warplanes during four days of large-scale military drills, and launched a record-breaking 80 missiles according to the Korean Central News Agency (KCNA) [1] . The North Korean Government justifies these provocations as a response to the “Vigilant Storm” joint military drills between the US and South Korea and increasing sanctions. This is reflective of the past decade’s trends in engagement with North Korea shifting towards strategic patience coupled with a global pressure campaign. A recent US Department of State briefing exemplifies this current stance:

“If the DPRK has the erroneous belief that the types of provocations that it has mounted… give it any additional leverage, the consequences that it will bear from the international community will prove once again that is not the case. The provocations that we’ve seen from the DPRK have only further isolated the DPRK regime.” [2]

Simultaneously, the health situation seems dire. In the past several months, North Korea has been facing a COVID-19 outbreak. Likewise, given the difficulties of closed banking channels, travel restrictions, and increasing sanctions, humanitarian aid to North Korea has been stifled, likely leading to exacerbation of health outcomes traditionally dependent in part by health aid.

Times of escalatory crisis often stir up fear and fatalism; yet they also provide ripe opportunities for creative shifts in diplomatic risk-taking. The questions arise–what is the next era of engagement with North Korea? Will the pressure continue mounting towards a boiling point, or can new diplomatic approaches avoid conflict?

This report analyzes trends in health aid to North Korea, the challenges posed by the COVID-19 pandemic, and proposes a path forward in health diplomacy.

Trends in Health and Humanitarian Aid to North Korea

Prior to the COVID-19 Pandemic, North Korea had exhibited a surprisingly robust healthcare system with relatively positive achievements on key health indicators, including its life expectancy of 72.3 years (a decade above the low-income nation average of 63.7 years). [3] The North Korean Government’s spending on health is estimated to be 6-7% of GDP – an expenditure which is several percentage points above the international average and one that has been sustained despite increasing sanctions. As recently as this summer of 2022, the government has been investing millions of dollars in ventilators, medicines, and other medical goods. And it has some of the highest health workforce per capita, including 3.5 doctors per 1,000 of population(which outranks South Korea). [4]

Despite this, North Korea continues to meet part of its humanitarian and health needs through support from outside parties. Sparked by the extreme famine and floods of the 1990s, China, the WHO, UNICEF, UNFPA, and the Global Fund became the predominant providers of health aid. [5]

The ongoing humanitarian situation, outlined in DPRK Needs and Priorities 2020[6] shows continued extreme need for aid, including 40% of the population suffering from food insecurity, 20% of children under five with stunning, and estimates of 16,000 people dying from TB within a year. This report was based on data prior to COVID-19 which has only exacerbated the humanitarian situation in North Korea. Last year, North Korea ranked third-to-last on the global health security index. [7] Already by 2019, the increasing sanctions had closed off many banking channels, leaving many humanitarian agencies with the only option of delivering funds directly by hand to in-country teams. [8] DPRK’s Foreign Trade Bank also blocked UN and other foreign transactions in 2021 in response to sanctions. With the advent of the pandemic, North Korea’s strict travel restrictions, and expulsion of foreign aid workers, this has in effect closed off corridors for humanitarian and health aid.

Recent NK News reporting shows that the UN has transferred $1 million USD to a North Korean bank account as a down payment on the money owed to the NK government for international organizations’ operating expenses. We have yet to see whether this is an exception or a harbinger of further opening. [9]

The Setbacks and Challenges of COVID-19 Diplomacy

The first years of the COVID-19 pandemic provided a unique opportunity for North Korea and the international community to engage in a diplomatic breakthrough on the basis of COVID-19 vaccines, testing, and therapeutics. However, the negotiations have stalled. In our recent article in International Affairs, we describe how failed vaccine provision negotiations with North Korea highlight the limitations of traditional donor-recipient aid relationships in this geopolitical context. In 2021, COVAX offered vaccines to North Korea twice, and both were declined: first, 2 million doses of the AstraZeneca vaccine, and later nearly 3 million SinoVac doses through UNICEF. In 2022, North Korea again declined offers of AstraZeneca and Novavax doses. [10]

Shortly after publication of our article, and preceding the US administration’s visit to South Korea in May 2022, the KCNA began to report of COVID-19 cases for the first time. Without testing capacity and reliable data, we have yet to see the full toll of how this has impacted the population of North Korea. According to state media data, the total “fever cases” reached 4.7 million people and caused 74 related deaths, which many experts worry is a significant underestimate given the low vaccination rates in the country.

North Korea continues to rebuff offers of COVID-19 assistance from the US and South Korea. A recent Wilson Center report argues that this behavior is, in fact, not new. North Korea refused medical aid from the WHO starting from back in 1952. [11] Although the global context has shifted drastically, we may discern key lessons around (mis)trust of foreign institutions and legitimacy in the eyes of the international community.

Global Health Diplomacy as a De-escalatory Path Forward

In recent years of engagement with North Korea, we have seen a concerning trend towards mounting escalations in security and sanctions coupled with a worsening humanitarian and health crisis, including failed COVID-19 diplomacy. We are in dire need of a de-escalatory off ramp. If the goal is de-escalation, evidence from the past couple decades suggests that the answer to North Korea’s provocations is not reciprocal provocation but rather negotiation and engagement. A CSIS report analyzing the period of 1990 to 2017 demonstrates an inverse correlation between North Korea’s provocations and bilateral/multilateral negotiations with North Korea. [12] Though this does not denote causation, one can reason interconnectivity between provocation and negotiation.

So the question arises, how can we bring parties back to a bilateral or multilateral negotiating table? One path forward would be through global health diplomacy (GHD), which is a conceptual framework that looks at the convergence between global responsibility and national interest. In traditional notions of international relations (IR), we hold a dualistic tension between a purist, apolitical conception of humanitarian aid versus an instrumentalist view of foreign affairs. GHD provides an alternative perspective that asks, how can we do both?

In a traditional IR approach, we try to separate security and non-security issues; but as we have seen, the two are deeply intertwined. North Korea’s nuclear provocations impact international sanction activity which impacts the capacity for humanitarian and health aid to operate in the country.

Instead, we look between the two extremes of idealistic aid and transactional negotiations. For donor countries, we ask, what would be in their enlightened self-interest and reflect their global responsibility? For North Korea, we ask, what does a first step towards international engagement rooted in Juche Sasang, economic empowerment, and health promotion of its people look like?

Historically health aid to North Korea has never met the strategic level forethought of a GHD framework. It has often been fragmented, uncoordinated, and subjected to political objectives. One proposal would be to engage North Korea in a long-term, coordinated health aid package. Key salient features would have to involve the following:

First, it needs to be owned, driven, and co-financed by North Korea. From the North Korean perspective this builds upon their philosophy of self-reliance; from the international community, this meets development cooperation principles. This is a first crucial step in building the minimum baseline of trust in a zero trust environment.

Second, it would be beneficial to be part of the existing broader proposed international efforts of post-pandemic recovery aid to low- and middle-income nations, aligned with standardized objectives, design, and evaluation. Any negotiating power and trust would crumble if North Korea felt singled out–either in an unfairly condescending or antagonistic manner.

Third, for instrumental purposes of ensuring that the aid helps the people that need it, this must be coordinated with strategically lifting, without precondition, the sanctions that hamper humanitarian aid to and health cooperation with North Korea. This would involve a targeted look at banking corridors, health equipment, and other relevant goods.

This is no doubt a diplomatic risk. There is a real possibility that North Korea may receive this aid, take advantage of lifted sanctions, and still continue on a path of nuclear provocation. Theoretically, it involves the risk of a loss of negotiating power. But even gradations of failure may have longer term benefits. Negotiation of a comprehensive and sustained health cooperation package would necessitate bilateral or multilateral talks, and it would allow such negotiations to begin on a less heated subject such as health rather than denuclearization.

Looking at previous international health cooperation programs, the risk of derailment is high, especially during times of rising military tension. If North Korea and the international community were to come to a common understanding about a comprehensive and sustained health cooperation package, we recommend developing a consensus framework for key stakeholders. Such an agreement would in essence assure de-linking of security issues from the implementation of the project. Thus within the GHD framework, the mechanical implementation of aid becomes de-politicized at the tactical and operational levels while the broader health aid package has potential to serve de-escalatory diplomatic interests at the strategic level.

Even if this none of the denuclearization or other security objectives come to fruition in the short term, the aid efforts would still have (1) the potential to build trust, (2) lay the groundwork for future engagement, and (3) most importantly, alleviate the dire health needs of North Korean people. The alternate risk of the status quo–of continued escalation, worsening suffering of North Korean people, and possible nuclear warfare is the far greater risk. The time is right to forge a new path forward through health diplomacy.■

[1] Colin Zwirko, 2022, “North Korea fired cruise missiles near ROK coast, new ICBM: State media” https://www.nknews.org/2022/11/north-korea-fired-cruise-missiles-near-rok-coast-new-icbm-state-media/ (Accessed: November 15, 2022)

[2] 2 U.S. Department of State, 2022, “Department Press Briefing – October 12, 2022” https://www.state.gov/briefings/department-press-briefing-october-12-2022/#post-387451-North%20Korea(Accessed: November 15, 2022)

[3] Kee B. Park, Edward I. Ham, 2021, “North Korea’s Surprisingly Robust Healthcare System” https://www.globalasia.org/v16no3/cover/north-koreas-surprisingly-robust-healthcare-system_kee-b-parkedward-i-ham(Accessed: November 15, 2022)

[4] Conversations with Kee Park; internal sources; WHO Country Co-operation Strategy

[5] Lee H, Ahn DY, Choi S, Kim Y, Choi H, Park SM, 2013, “The role of major donors in health aid to the Democratic People's Republic of Korea.” J Prev Med Public Health 46(3):118-26.

[6] UN OCHA, 2020, “DPR Korea Needs and Priorities Plan 2020” https://dprkorea.un.org/sites/default/files/2020-04/2020_DPRK_Needs_and-Priorities_Plan.pdf (Accessed: November 15, 2022

[7] Global Health Security Index, 2021, “2021 GHS Index Country Profile for North Korea” https://www.ghsindex.org/country/north-korea/ (Accessed: November 15, 2022)

[8] UN Security Council, 2019, “UN Panel of Experts, S/2019/691, 30 Aug. https://www.securitycouncilreport.org/atf/cf/%7B65BFCF9B-6D27-4E9C-8CD3-CF6E4FF96FF9%7D/S_2019_691.pdf (Accessed: November 15, 2022)

[9] Chad O'Carroll, 2022, “UN sends $1M to North Korean bank account for ‘humanitarian assistance’” https://www.nknews.org/2022/11/un-sends-1m-to-north-korean-bank-account-for-humanitarian-assistance/ (Accessed: November 15, 2022)

[10] Dong Jin Kim, Andrew Ikhyun Kim, 2022, “Global health diplomacy and North Korea in the COVID-19 era.” International Affairs 98(3): 915–932

[11] Yemok Jeon, 2022, “What can Korean war teach us about bringing covid-19 vaccines to North Korea?” https://www.wilsoncenter.org/blog-post/what-can-korean-war-teach-us-about-bringing-covid-19-vaccines-north-korea (Accessed: November 15, 2022)

[12] Lisa Collins, “25 Years of Negotiations and Provocations: North Korea and the United States” https://beyondparallel.csis.org/25-years-of-negotiations-provocations/(Accessed: November 15, 2022)

■ Andrew Ikhyun KIM is a physician passionate about health diplomacy and peacebuilding. He recently served as a White House Fellow within the Biden-Harris administration. His recent research explored vaccine diplomacy and humanitarian aid to North Korea, and he has worked in the past on the first systematic review of health literature in North Korea and on organizing multiple science and health diplomacy forums between the Koreas and the US. As a physician at UCSF, he co-wrote a report for the WHO’s Pandemic Preparedness Panel on US COVID response. His prior work on the nexus between peace and health spans projects in Liberia during the 2014 Ebola outbreak, eastern Uganda, and South Sudan. He earned his MD from Harvard Medical School, MPhil in International Development at the University of Cambridge, and BA from Brown University.

■ Typeset by Junghoo Park, Research Associate
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