A guerrilla health care system for North Korea’s poor

Gullible leftists and U.N. nincompoops who take North Korea’s claims of socialist equality at face value love to bleat about the wonders of its free universal health care, but those bleats have little basis in reality. A 2010 study by Amnesty International found that Pyongyang provides less for the care of its non-elite citizens per capita than almost any other nation on earth:

The North Korean government has failed to adequately address the country’s ongoing food shortages since the 1990s. This failure has led to the current critical situation in which the population faces severe health problems associated with malnutrition. Compounding these problems, North Korea’s government has failed to provide adequate resources for its health care system, which as a result is wholly unable to cope with the growing number of illnesses and diseases of a population weakened by hunger.
According to the WHO, North Korea spent less than US $1 per person in 2006. [….]
In fact, North Korea had one of the lowest recorded per capita total expenditure on health in 2006 of any country in the world.105 The state’s paltry expenditure on health, in spite of the urgent need for medical training, access to medicines and public health education, violates North Korea’s obligation to provide for the basic health of its population. [Amnesty International]

Outside Pyongyang, clinics lack basic medicines and supplies, and care is available only to those who pay for it with cigarettes, alcohol, or cash. Doctors often receive little or no pay, so they demand payment from their impoverished patients instead. According to one refugee interviewed by Amnesty:

“People in North Korea don’t bother going to the hospital if they don’t have money because everyone knows that you have to pay for service and treatment. If you don’t have money, you die. People without money just have to hope that they don’t get sick or can get better on their own. Doctors will not treat patients without compensation, especially for surgery. Nothing is free anymore.” [Amnesty]

Sick people who can’t get medicine are forced to rely on traditional medicine, or use methamphetamine or heroin as substitutes. Women, including those whose circumstances have forced them into prostitution, take heroin in the false hope that it’s a contraceptive. Communicable diseases (1, 2, 3, 4) spread widely. Tuberculosis is rife; even in the army, it goes untreated until the soldier is sent home to die. Medicines donated by aid agencies show up for sale in markets. While Pyongyang exports doctors to Africa and the Middle East, inside North Korea, the demand for medical services so exceeds the supply that some sick people seek out unqualified healers instead. The actual doctors who remain have gone into business for profit, and not unreasonably; after all, doctors need to eat, too:

“More recently, there have been doctors who diagnose patients and others who fill in prescriptions. The medicine is then sold to patients, so trade in this field is growing.”

This trend was corroborated by two additional sources in North Pyongan Province.

The most crucial element in medical treatment is an accurate diagnosis, which is why so many people in the past had died from cirrhosis and ascites. However, recently those numbers have been falling thanks to a greater wealth of medical experts offering services through the back door, according to the source. [Daily NK]

Some of these providers are retired doctors from state hospitals. Others are unlicensed healers.

“The free medical system has been lost on people, leaving them without any treatment unless they pay up bribes at state hospitals. Struggling to even receive a proper diagnosis, people have been seeking out these doctors,” the source said. This has led to the build-up of a much more structured, systematic, and specialized market for health care.

Some Korean medicine doctors who have earned great reputations see patients lining up in front of their doors from the crack of dawn. They charge around 10 USD for a diagnosis, and the cost for prescriptions varies widely depending on the medicine required for treatment, according to the source. [Daily NK]

The regime periodically cracks down on this trade, but now that even high officials have begun relying on free market medical care, they can’t completely suppress it, either.

This evidence not only refutes the unserious narrative of North Korea as a model for public health services, it also raises more serious questions of whether foreign aid programs that channel their funds, supplies, and medicines through the state work. The beneficial impact of these programs is probably greater than zero, but they certainly haven’t been a broad solution North Korea’s public health crisis. It suggests that donors need a better use for their scarce aid resources than pouring them into the black hole of Pyongyang.

As is the case with North Korea’s food crisis, the market-based solutions that North Koreans have found are both a symptom of the problem and a potential solution to it. One wonders: if the regime allocates medical services based on the patient’s political caste, and if this has, de facto, further reallocated services based on one’s economic class, why can’t NGOs find ways to pay North Korean doctors to treat the patients whose need is greatest — starting with North Korea’s orphaned children? We know that it’s possible (though it has become more difficult) to send money to specific North Korean recipients. If so, a trusted intermediary, such as the stay-behind relative of a refugee in the South, can be taught to screen patients, and to pay doctors to see and treat the patients whose need is greatest.

This certainly isn’t a long-term solution. Paying doctors to treat some poor patients will put additional demand on a limited supply of providers, and drive up the cost that other poor North Koreans pay for them. Because the regime is only willing to provide so many doctors, it would also draw more unqualified healers into the medical services market. That’s why it will eventually be necessary to increase the supply of medical providers. How can that be done in a closed system like North Korea’s? One solution may be telemedicine, which American doctors are already using to diagnose and treat patients in distant, far-flung, underserved communities now, and which NGOs are also exploring as a way to provide medical services in other poor countries.

In the case of North Korea, the extra doctors might be volunteer physicians in South Korea, the United States, or Europe. It is already possible (though, again, increasingly difficult) for North Koreans to call across their country’s northern border by piggybacking on Chinese cell networks. There is no good reason why South Korean cell networks couldn’t also expand into North Korea, and open a second front in the war against Pyongyang’s information blockade. If the network existed, the markets would soon provide the phones that could utilize that network. In the same way that North Korea’s guerrilla financial system can send money to recipients inside North Korea, the market could develop the capacity to send medicines, even prescriptions, to those in need of them.

There are, of course, technological challenges: telemedicine requires the doctor to be able to speak with the patient, and often, to see high-resolution imagery of the patient to observe symptoms. In the short term, full-service telemedicine is probably asking too much. Pyongyang is cracking down hard on North Koreans who make calls over the Chinese network, and one assumes that it would crack down even harder on those who used a South Korean network. But whatever the limitations on the imagery and video those phones could take and upload, it would be a vast improvement over what North Koreans have now: nothing.