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COVID-19 in the Two Koreas

Howard Waitzkin is distinguished professor emeritus of sociology and health sciences and former director of community medicine at the University of New Mexico. His recent writings include Health Care Under the Knife: Moving Beyond Capitalism for Our Health (Monthly Review Press, 2018), Rinky-Dink Revolution (Daraja Press, 2020), and, with Alina Pérez and Matthew Anderson, Social Medicine and the Coming Transformation (Routledge, 2021).

Capitalist health care systems do not do well in epidemics compared to health care systems not organized around capitalist principles, and COVID-19 is no exception. As Paul Sweezy once pointed out (as relayed by Barbara Ehrenreich), if health care is the purpose of the U.S. system, it fails miserably. But, in reality, the system is successful, because the goal is something else: profit making and the accumulation of capital.1 With its corporate dominance, horrendous problems of access, high costs, lack of overall coordination, and deprioritization of public health services, the United States has confronted the pandemic with chaos. In general, government agencies and corporations have struggled to protect the previous profitable, though ineffective, arrangements, with deadly consequences.

A few countries have done relatively well in responding to COVID-19, and they all approach health care and public health very differently from the United States, even if their economies are capitalist. I focus now on one of those countries that I know best: South Korea. I then move the focus to that other mysterious, noncapitalist country on the same peninsula: North Korea. Although I explain these countries’ initiatives to control the downstream effects of COVID-19 in sickness, suffering, and death, I also report what if anything the two Koreas have done about the upstream causes of the pandemic in the industrial production of food and the destruction of natural habitat.2 This work is part of an effort to understand the ways that countries with different political-economic systems have approached COVID-19, and how they are likely to approach future pandemics that may be even worse.

Contradictions of Success in South Korea

I have experienced the pandemic both in the United States and South Korea. My partner and comrade, Mira Lee, is a doctor from South Korea, and I worked there during 2019 as a Fulbright senior fellow, teaching public health at Seoul National University.3 I also have continued to work part-time at community health centers in the United States, most recently in February 2020, as South Korea already had seen improvements in the pandemic and the U.S. encounter with the virus was rapidly worsening. In South Korea, I gathered information from publicly available bibliographic and media sources, interviews with colleagues and community residents, emergency cell phone messages, and unobtrusive observations at hospitals and community health centers.

Officially known as the Republic of Korea (ROK), South Korea is a capitalist country whose policies link closely to those of the United States. Some activists and scholars consider South Korea as a U.S. “neocolony.” Korea’s adoption of Western medicine started in the late nineteenth century, due to efforts of U.S. missionary doctors and nurses. Yet it is hard to imagine COVID-19 policies that differ more than those of these two countries.

The capitalist state in the ROK contains a welfare-state component with a single-payer national health program. In its relatively well-organized and funded public health infrastructure, personnel work in the public sector without apparent organizational motives to enhance corporate profitability. The organized medical profession, especially through the Korean Medical Association, usually leans toward the right, but several groups of doctors and public health professionals oppose the association and support progressive policies.

Some political, economic, and cultural features provide a context for the pandemic.4 In the military realm, South Korea continues its interlocking relationship with the U.S. military-industrial complex. The ROK’s military expenditures have increased in a linear pattern since 2010. Although less unequal than the United States, South Korea’s social inequality has, during recent years, worsened to the highest level among East Asian nations. The impact of inequality on daily life is substantial, as depicted in the prize-winning film Parasite. Competitive values within South Korean society affect mental health and well-being, especially among young people who must fiercely compete for university placements and jobs. The suicide rate is the highest among Organisation for Economic Co-operation and Development countries. Although South Korea’s cultural productivity has achieved global impact—for instance through K-pop with its frequent messages of love, respect, and mutual aid—multiple young stars have committed suicide.

Often described as a homogeneous society, South Korea’s diversity expresses itself partly through geographic marginalization. The population has become concentrated in a small number of urban centers as the countryside has become depopulated. This trend has created health care access problems even within the single-payer national health program, especially in the rural south and southwest, as well as problems of isolation and loneliness for the elderly population.

Some historical experiences influenced South Korea’s response to COVID-19. During the epidemic of Middle East respiratory syndrome in 2015, the government of president Park Geun-hye received harsh criticism for its disorganized and secretive approach to case finding and treatment, which the government later claimed was intended to prevent anxiety and panic. A similar lack of transparency caused distress throughout the country earlier in 2014, when Park and her colleagues did not communicate honestly and supportively during a disaster in which a ferry boat, the MV Sewol, sank and 304 people died, mostly high school students. These events, plus scandals around corruption, led to Park’s impeachment in March 2017 after months of protests, comprising the so-called Candlelight Demonstrations. After Moon Jae-in’s more progressive presidency began in May 2017, the Ministry of Health and Welfare initiated multiple reforms and new programs, including a sophisticated plan for responses to future epidemics.

The South Korean government reacted quickly and decisively when the seriousness of the COVID epidemic in China became clear in January 2020. South Korea implemented several distinctive policies and practices:

  • No travel ban: South Korea has not prohibited travelers from any country. Even during the early phase of the pandemic, when it reported the second-highest number of cases after China, it did not ban travelers from China. This policy has led to strange situations like Korean airlines ending up the only ones operating international flights during certain time periods at some international airports such as Los Angeles.5
  • Aggressive, mandatory diagnostic testing for travelers and residents at high risk of infection, with mandatory contact tracing, quarantine, and treatment if needed: At certain times, all travelers to South Korea from some countries, including the United States, have had to accept a mandatory two-week period of supervised quarantine. To reduce financial insecurity and inconvenience for people in quarantine, the government has provided subsidized housing and food at rented facilities including luxury hotels with otherwise low occupancy during the pandemic. High-technology approaches including required GPS cell phone apps have assisted with contact tracing and quarantine procedures. To protect privacy, the government has identified places rather than individual people to help in tracing contacts. A well-organized and financed system of public health clinics at the county level has implemented these epidemiological procedures, coordinated from the national and provincial levels of government. These techniques have led to remarkable successes in containing transmission, for instance from churches, enclosed workplaces like call centers, nursing homes, and even community kimchi-making festivals.6 In short, South Korea has applied all the straightforward procedures taught in Epidemiology 101, while the United States and multiple other capitalist countries have not been able to implement anything similar.
  • Medical, financial, nutritional, and social support from government and public health agencies and community health centers at the local level: Everybody can receive free or very low-cost medical care through the single-payer national health program. Coordinated at the national, provincial, and county levels, public health agencies also provide other needed services for people in quarantine and for individuals, families, businesses, and other organizations experiencing adverse financial impacts. Through a simple application, all Korean citizens and permanent residents periodically can apply for grants through debit cards that they can use only for purchases from local merchants. Rather than means testing for grants according to income or wealth, the government encourages people not to apply if they felt they did not need the assistance.
  • No general lockdown and limited overall economic impact of the pandemic: Most businesses have stayed open. These include businesses serving the public such as restaurants, bars, gyms, singing rooms, and so forth, although periodic restrictions have limited numbers of customers and hours of operation. Messages from government agencies encourage people to practice social distancing and avoid such businesses, as well as religious and cultural organizations, until notified that the locations have been decontaminated and safety improved due to decline in new cases. The government requires all organizations to comply with epidemiological procedures such as contact tracing and decontamination if a case is diagnosed.
  • With rare exceptions, no coercive command techniques by government: The government has made recommendations but has issued very few orders. One such order involved school closures for several months, for which the government provided an explanation regarding increased risk of contagion that actually was not clearly supported by epidemiological research (a South Korean study showed the importance of contact tracing when schools do reopen).7 In general, the government encouraged voluntary adherence with recommendations rather than using coercion.
  • Procedures to strengthen transparent communication with the general population: The national government has operated twice-daily news conferences, extensive media broadcasts, and cell phone-based messaging. The cell phone messages, labeled “emergency disaster alerts,” are distributed by the Ministry of the Interior, which translates them automatically into English and Chinese. The messages convey sensitivity to people’s feelings, needs, cultural traditions, and security. On a single day, an individual may receive around one hundred messages from different levels of government at the federal, provincial, county, and municipal levels.

The cell phone disaster alerts reveal a great deal about South Korea’s decentralized, participatory processes during the pandemic. During spring 2020, the alerts emphasized the sad necessity of not going in groups to view the beautiful cherry blossoms. As the seasons passed, the messages acknowledged disappointment about missing other cultural traditions that became problematic during the pandemic: folks enjoying the beach in summertime; families returning from cities to their ancestral villages on chuseok (roughly similar to Thanksgiving) to cut weeds around their ancestors’ graves and celebrate their memory; group excursions to see the colors of autumn leaves; organized efforts to support high school students’ tense experiences with the national university qualifying exams; and then the winter holidays leading to lunar new year.

Cell phone messages, which arrive at almost any time of day or night, vary in content and usually pertain to the local level. The impact of the messages on people’s attitudes and behaviors is unclear. At the least, the messages communicate that many people at all levels of public health and government are working hard to provide information that will help themselves and others cope with the pandemic.

Here are some simple categories and examples from messages that I gathered, using a computerized random sampling method.

  • Concrete information about local COVID-19 spread. This information comes mainly from local levels of government, based on communication between public health personnel and government officials responsible for the emergency notifications. The information includes statements assuring the safety of visiting locations after decontamination, such as small businesses. For example:
    • “[Yeongdong County Office] 7.9 (Thu), if you have visited ‘Jjamppongui Daega (Chinese Restaurant)’ between 11:30~12:30 in Yangsan-myeon, Yeongdong-gun, please contact Yeongdong-gun Public Health Center (043-740-5611~2). 2020-07-17 12:52”
    • “[Gwangju Metropolitan City] Since we have completed the disinfection and sterilization of the facilities visited by confirmed case: Hwangtaemyeonga Yongdaeri Deokjang, Yege Chamchi, Maewol Heukyeomso Garden, you can visit there without worries. 2020-07-17 17:13”
  • Specific information about the travel history of new cases, and what to do if people have visited those places at those times. For example:
    • “[Gwangju Metropolitan City] The confirmed case Jeonnam no. 9 (M, 20s) The travel history in Gwangju 1 3.26 (Thu) 09:25 Arrive at Incheon International Airport (Entry from Thailand) 14:30 Youth Square 15:05 Shinsegae Department Store (Gucci Store). Wore a mask. 2020-03-29 10:18”
    • “[Gangjin County Office] If you have visited places where Mokpo City’s Patient No. 3 went- Mokpo Laito PC Room North Port Branch (3/27 19:26 ~ Dawn 01:05), should report to Gangjin County Public Health Center (061-430-3592). 2020-03-29 10:17”
  • General recommendations about prevention, tailored to local conditions and cultural traditions, such as:
    • “[Cheongju City Hall] To overcome COVID-19, let’s actively practice in social distancing. In particular, please be patient with cherry blossom viewings this year. 2020-03-29 10:00”
    • “[Jeonnam Provincial Government] When using swimming pool, bathing beaches, valleys and rivers in summer season, be sure to wear a mask outside of the water, and ‘keep distance’ between people even in the water. 2020-07-18 09:00”
    • “[Gangjin gun Office] Today, confirmed cases 7.18. (Sun), it is announced that the child of the patient’s child became self-isolating confirmed. 2021-07-22 20:59”
    • “[Gangjin-gun Office] One confirmed case occurred during self-isolation (no movement). It is filial piety and love of hometown for children who live in large cities to postpone their visit to their hometown for a while during the holiday season. 2021-07-22 20:22”
  • Each message has different text, indicating that separate people are writing messages at each governmental level, with some similarity of content based on current national and provincial policies. The inclusion of local writers producing locality-specific messaging resonates with prior findings about the importance of community participation rather than top-down messaging in public health responses, such as Ebola and COVID-19 in Africa.8

Efforts to control the epidemic and also to prevent economic collapse became notable public health accomplishments. To consider just one point in time: as of Christmas 2020, South Korea experienced its third wave of the pandemic, with increases in numbers of new cases to the level of about 1,000 daily in a population of about 52 million people.9 If South Korea had a similar population to the United States, about 330 million, this rate of new cases would amount to about 6,300 per day, rather than the roughly 200,000 that the United States was experiencing, or even higher considering the obvious problems of underdiagnosis and under-reporting. At the same time, South Korea’s deaths from COVID-19 totaled about 800; if adjusted to the size of the U.S. population, the deaths would total about 5,000, compared to actual U.S. deaths of 322,000.

Moving ahead to mid–July 2021, South Korea experienced a troubling fourth wave, with about 1,200 new cases daily and total pandemic deaths climbing to just over 2,000. If adjusted to the U.S. population, new cases would have numbered about 7,600 daily and total deaths about 12,600. In contrast, during the same period, the number of new cases daily in the United States vastly improved to about 30,000 (still more than four times South Korea’s rate, adjusted to the U.S. population) and total deaths increased to just over 600,000 (forty-eight times higher than South Korea’s total, adjusted to the U.S. population).10

Although South Korea quickly obtained supplies of the vaccines, there was no immediate plan to deliver the vaccines through a population-based program, but rather a longer-term plan to begin later in the winter and spring 2021. By mid–July 2021, over a quarter of the population had received at least one dose. Plans were on schedule to achieve 70 percent vaccination with the first dose by the end of September 2021, with herd immunity predicted during the following winter. Strict public health surveillance continued, as distancing procedures tightened with the increase of new cases during the fourth wave. As well as some concerns about efficacy, safety, and costs, the reasons for not emphasizing vaccine mostly have to do with the relative success of standard epidemiological methods to control infectious outbreaks, especially social distancing and wearing masks.

Some controversies and criticisms have arisen. The Korean Medical Association resists any policy of the Moon government that interferes with private practitioners’ ability to work without obstruction. Thus, strengthening the country’s public health infrastructure in response to the pandemic has led to protests by the Korean Medical Association against further regulatory controls and opposition to policies like not closing the borders to travelers from China and starting new medical schools in rural areas to improve primary care services.

Left-leaning critics in South Korea, while expressing general support for the government’s policies, have called attention to some fundamental problems.11 The private sector continues to provide most medical services, with socialized funding under the single-payer national health program. Partly due to the predominance of private services, South Korea lacks an organized approach to primary care. People tend to seek specialty rather than primary care, especially from elite medical institutions in Seoul. The contradiction between private and public sectors has created inefficiencies and challenges for public health coordination during the pandemic.

Social and economic inequalities rooted in class structure have impeded public health initiatives. For instance, during the pandemic, working-class employees at call centers and delivery services have faced higher risks of infection, adverse health effects of overwork, and some difficulties in obtaining needed care. Multiple people employed as outsourced couriers for logistics companies, unprotected by labor laws, reportedly have died from gwarosa, a Korean term referring to death from overwork.12 From the perspective of gender inequality, critics also have called attention to the predominance of men at most levels of government and public health decision-making, as well as the disproportionate caretaking role of women during school and work closures.13

During the pandemic, South Korea has not addressed or even called attention to the upstream causes of COVID-19 and similar epidemics through capitalist industrial agriculture, mining, development projects, and other processes that lead to the destruction of natural habitat. Processes aiming to accumulate capital through habitat destruction have grown more pervasive, even though historically such habitats have protected against pandemics. Although South Korea reversed the earlier severe deforestation brought about mainly through exploitation of wood products by the Japanese empire during the first part of the twentieth century, there are important exceptions, such as the destruction of ancient forests to build skiing facilities for the 2018 Olympics. South Korean corporations such as POSCO have devastated natural habitats in other countries, as in the construction of palm oil plantations. Under international pressure, POSCO recently promised to stop these efforts and even to provide compensation that can be used for habitat restoration.14

Meat consumption has increased markedly in South Korea, along with production of pork and chicken products through large industrial farming enterprises. South Korean animals raised for meat suffer from periodic viral epidemics, including African swine fever and swine acute diarrhea syndrome, the latter caused by a coronavirus that reportedly has not yet been documented to cause significant human infections. South Korea’s lack of expressed concern about industrial meat production as an upstream cause of pandemics remains a contradiction of public health policies.15

However, as in multiple other countries, a network of farmers has been studying and trying to implement a return to peasant agriculture. For instance, in the rural southwest, farmers held a study group reading a Korean translation of an important book showing the advantages of peasant agriculture in terms of costs and efficiency, in comparison to capitalist agriculture.16 These farmers aim to transform industrial monoculture crop production as well as meat production processes that foster viral epidemics due to unsanitary practices. Resistance to expansion of factory farms for pork and chicken production has been growing. In general, these efforts remain separated from public policies to address agricultural practices that increase the likelihood of pandemics.

Ambiguous Realities of Success in North Korea

The Korean peninsula also contains a country with a noncapitalist political-economic system. An assumption in the dominant media, including the dominant public health media and even some left-wing media, is that any data from the Democratic People’s Republic of Korea (DPRK) are unavailable, inaccurate, or untrue. Horror stories about North Korea based on limited information abound throughout the world, so, in asking the question about the pandemic’s impact there, I expected to find either completely inadequate information or a very adverse situation. However, the hegemonic portrayal of North Korea may not be fully accurate, as reported in a comradely though somewhat critical account in 2008, based on in-person observations, by an astute social historian: Fidel Castro.17

Thus, last year I decided to study the DPRK’s health care system in the public health courses I coordinated in Seoul. Reportedly, this was the first such attempt at teaching about North Korea at the ROK’s leading School of Public Health. Trying to keep an open mind about North Korea can become a surprising experience. As with my observations about South Korea, what I am reporting here came from publicly available sources, plus interviews with South Korean colleagues who have visited the DPRK for public health collaborations. Going there myself as a U.S. citizen was difficult before the pandemic and essentially impossible during it. I do not intend the following account as “truth,” but rather as an effort to make sense of some surprising information.

We were able to find much more information than expected. The World Health Organization (WHO) maintains a country office in Pyongyang and issues regular reports about the DPRK. As one example, a collaborative report by WHO and the DPRK’s Ministry of Health, published by WHO in 2016, presented an apparently honest account of the country’s major public health challenges, including a high rate of smoking (the report emphasized a smoking rate of 54.5 percent of the adult male population), nutritional difficulties, outbreaks of infectious diseases, inadequate services with disappointing outcomes in maternal and child health, respiratory disease from indoor air pollution, and thyroid disease from insufficient iodized salt.18

The collaborative report, Message from Honourable [DPRK] Vice Minister of Health and WHO Representative to DPR Korea, emphasized that “in DPR Korea, health policies are being made and implemented based on the great people-centered Juche idea and on the principle of serving the best interests and health promotion of the people.” Juche refers to a reinterpretation of Marxism-Leninism by Kim Il-sung, North Korea’s revolutionary commander during the struggle against Japan and the DPRK’s supreme leader beginning with independence from Japan after the Second World War. Kim presented this reinterpretation respectfully, praising Marxism-Leninism while arguing that the Korean context required modifications through a less “dogmatic” approach.19 Through Juche, Kim tried to resolve the continuing challenges of building “socialism in one country,” as opposed to a worldwide revolutionary struggle in which international solidarity could facilitate revolutions in multiple countries. These contrasting strategies preoccupied V. I. Lenin, Joseph Stalin, Leon Trotsky, and many others, generating fierce and sometimes deadly conflict.

Focusing on revolutionary struggle in Korea, Kim argued for the importance of analyzing Korea’s unique history, strengths, and needs, rather than applying a more general model based on the Soviet Union or China. He emphasized that a Korea-centered strategy also fostered and benefited from international solidarity. From this viewpoint, Korea’s future depended on sustainability through agricultural self-sufficiency and a lack of dependency on other nations, including socialist nations. Because historical and material conditions differed across nations, Kim argued, Korea must advance its own revolutionary policies. Although historical and material conditions were important, according to Kim, they were not determinate in shaping human history. Instead, Kim focused on the human “subject” and especially the importance of leadership by individuals like himself. As the 2016 WHO-DPRK report points out, Juche clearly serves as a conceptual basis for the DPRK’s public health policies. In particular, an emphasis on North Korea’s unique historical and material conditions, self-sufficiency and independence, and the key roles of the human subject and leader figure prominently in the DPRK’s responses to the COVID-19 pandemic.

In the rare instances that Western media report on public health initiatives in North Korea, the reports usually question the veracity of the DPRK government’s claims or otherwise diminish the importance of the accomplishments. For example, on November 5, 2020, during the pandemic, the New York Times reported on the DPRK’s public acknowledgment that smoking, which affected 46 percent of the country’s adult men as of 2017 according to WHO (somewhat lower than in the 2016 report mentioned earlier), had become a major public health problem.20 As in China and some other countries, public health approaches to reducing smoking are weakened by the contradiction that a state-owned and -operated tobacco industry has relied on smokers’ cigarette purchases to generate a substantial part of the government’s revenues. The New York Times article also belittled the initiative by emphasizing that Kim Jong-un was continuing to smoke, just as U.S. media belittled Cuba’s mostly successful anti-smoking campaign by emphasizing Castro’s continued smoking of cigars, until he eventually quit.

North Korea suffers from serious shortages of medications and equipment, partly due to the extensive economic sanctions imposed and enforced by the United States and the United Nations. At the United Nations and other diplomatic venues, the United States leads efforts to punish the DPRK for developing nuclear weapons and related policies as methods to protect its survival and sovereignty in the context of more than seventy years of hostility since the beginning of the Korean War. The Carnegie Endowment for International Peace has documented the extensive scope of these sanctions, the goal of which is to damage the DPRK’s economy by restricting its ability to export and import key products, participate in trade with other countries, and conduct international financial transactions. In January 2021, at a congress of the DPRK’s Workers’ Party, Kim Jong-un officially acknowledged that his five-year economic plan had mostly failed to achieve its goals.21

Despite these problems and others, including periods of droughts, floods, and other natural disasters leading to famine and economic crises, the DPRK’s health indicators are more favorable than usually recognized. Health personnel like doctors and nurses per population and health outcomes like infant mortality and life expectancy are generally better than other countries in East and Southeast Asia at similar levels of economic development. For instance, a study using data from WHO and other sources, published in the generally conservative Journal of the Korean Medical Association, showed that the DPRK’s life expectancy, age-standardized mortality, underweight among children under 5 years old, infant mortality rate, mortality rate among children under 5 years old, and maternal mortality rate were worse than more economically developed South Korea, but comparable or substantially better than those of Myanmar, Nepal, Bhutan, the Southeast Asian region as a whole, and global averages. As in China, traditional Korean medicine is integrated into the medical education as well as primary care in health centers.22

The DPRK has cooperated with WHO and other international health organizations, including the Gates Foundation, in strengthening its childhood immunization programs. As a UN agency, WHO does a balancing act in the context of the severe UN sanctions against the DPRK. WHO’s work with the DPRK officially falls under the categories of collaboration that the UN promotes despite the sanctions: “Food and Nutrition Security, Social Development Services, Resilience and Sustainability, and Data and Development Management.” In 2016, WHO presented its annual award for the Southeast Asian region to Sri Lanka and the DPRK “for their remarkable and sustained role in the public health gains of their countries.”23

WHO recognized the DPRK again in 2018 for eliminating measles, as evidenced by “interrupted transmission of indigenous measles for more than three years” through its vaccination programs—an accomplishment the United States and multiple other rich capitalist countries have not yet achieved. WHO’s Regional Office for Southeast Asia released a detailed report, Eliminating Measles: A Look at How Democratic People’s Republic of Korea Did It, which documents the collaborative procedures used and the verification processes coordinated between WHO and the DPRK. In the report, WHO’s regional director wrote, “DPR Korea’s example is a shining example to other nations struggling to control infectious diseases, and WHO very much looks forward to its continued partnership with DPR Korea as it continues to provide assistance and support in the control and elimination of other vaccine-preventable diseases.” Through their websites, WHO and the United Nations explain their goals and activities in the DPRK, refer to recent planning documents, and provide further information about WHO’s country office in Pyongyang.24

The DPRK’s dramatic actions to address COVID-19 seemed to aim toward a single goal: protecting the North Korean population from the pandemic, despite predictably detrimental economic effects. This apparent goal appeared unexpected and counterintuitive, based on mainstream, hegemonic views about the government’s despotic purposes. But these policies also resembled those of several other countries or states with noncapitalist political economies.

To combat COVID-19, the DPRK government quickly initiated drastic policies. On January 21, 2020, it closed its borders for all international travelers, apparently the first country in the world to do so. Foreigners and North Korean nationals with possible exposures experienced mandatory quarantine of up to one month in government-provided residential facilities. Sharing a border and maintaining extensive economic interactions with China, its main trading partner, North Korea through these measures greatly reduced the entry of people from China who might have harbored the virus. Testing people at risk for infection was done through kits provided mainly through donations from other countries, especially Russia. During the pandemic, the DPRK quickly constructed a large new general hospital in Pyongyang. North Korean state media, especially Korean Central Television and several state radio stations, have provided information about the pandemic for the population, almost all of whom own televisions or radios.25

During the early months of the pandemic, the DPRK curtailed nearly all trade with China, including the imports of essential Chinese products and exports of North Korean raw materials and consumer products that had generated rare sources of needed currencies. Over time, the government allowed the resumption of some imports, especially by train, but publicized an elaborate process of sterilization and multiple weeks of quarantine for these products. North Korea had developed several tourist resorts in the mountains near the Chinese border, and these facilities generated increasing earnings mainly from Chinese tourists; during the pandemic the border remained closed to tourism.

The DPRK did not lock down any cities until late July 2020, when the government declared an emergency because a defector from North Korea secretly came back from South Korea, where he had been reported as possibly infected with coronavirus. Kaisong, a city near the border to which the defector returned, was locked down until mid–August, as he and numerous contacts were quarantined and reportedly tested negative.26 While Kaisong was locked down, the government was also working to reduce the effects of flooding on food supplies and housing.

Throughout the pandemic, the government generally tried to assure that people’s jobs would continue and that the economic impact on individuals and families would be limited. The absence of private corporations needing to pay both workers and shareholders enhanced the government’s ability to continue employment in public-sector jobs. Greater tolerance and even encouragement of informal markets, especially for selling food products produced on small farms, have been reported during the pandemic.

By closing its borders and continuing a nearly complete ban on travel to the country, the DPRK has taken a very different direction from South Korea, and the rationale is not fully clear. Speculation focuses on the deficiencies in health care infrastructure for treating COVID-19, largely due to the impact of economic sanctions on the availability of hospital facilities, needed medications and equipment, lab capabilities to perform extensive testing, and public health personnel to trace contacts and manage quarantines. However, the government has not explained specifically why it decided to implement the drastic measures that it did, much earlier than most other countries.

WHO’s staff members have participated actively in the DPRK’s efforts to address COVID-19. These staff members are responsible for obtaining and reporting accurate health statistics from North Korea, as similar staff do in other countries. The accuracy of this information depends on local public health officials who gather the primary data in the many countries where WHO maintains “country offices,” which WHO established in Pyongyang during 2001. In countries where WHO does not maintain a formal office, WHO staff members still communicate with officials in the countries when compiling public health statistics. Questions about the accuracy of public health statistics arise throughout the world regarding not only COVID-19 but also other indicators, such as infant and maternal mortality. In its reports, WHO and other organizations like the World Bank provide estimates of statistical error and range of data accuracy.

The WHO country office in Pyongyang assumed responsibility for verifying reports about COVID-19 in the DPRK. According to WHO’s website, personnel in this office include the WHO representative, an administrative officer, and four “technical staff” members. Consultants and other outside experts travel to the country office each year for “training, capacity building and technical assessments, and program review.”27

Since November 2019, including the entire COVID-19 pandemic, Dr. Edwin Salvador has served as the WHO representative for the DPRK. In that role, he assumed responsibility for confirming WHO’s data about the pandemic. He personally has communicated with the media on multiple occasions about coordination between WHO and the DPRK government, as well as details of the DPRK’s initiatives and policies during the pandemic.28 Dr. Salvador is a native of the Philippines, where he received his medical degree. For postgraduate training, he studied at the University of Liverpool in the United Kingdom. Early in his career, he worked for ten years with Doctors Without Borders and the International Medical Corps, addressing public health challenges in multiple countries of Africa and Asia. He joined WHO in 2006 as a public health officer in Sudan. Later, he served at WHO country offices in Myanmar, Sri Lanka, and Nepal, receiving WHO’s 2016 Award for Excellence for his contributions after the catastrophic 2015 earthquake in Nepal. Before coming to the DPRK, Dr. Salvador held a position as WHO’s Deputy Representative in Bangladesh, where he coordinated WHO’s response to the crisis of Rohingya refugees from Myanmar.

Throughout the pandemic and until mid–July 2021, WHO’s COVID-19 scoreboard for the DPRK has shown zero confirmed cases and zero deaths.29 The New York Times tracking project also reports zero cases.30 Other prominent tracking venues—for instance, Johns Hopkins University, the Institute for Health Metrics and Evaluation at the University of Washington, University College London, Oxford University, the Washington Post, and the Guardian—do not report any data for the DPRK. Despite skepticism expressed in the dominant media by public health commentators, specific reasons for the skepticism remain vague.

At the end of June 2021, the government’s KCNA news agency reported that, during a politburo meeting of the ruling Workers’ Party, Kim Jong-un announced a “grave” COVID-19 incident that had threatened public safety. The report noted that members of the politburo were recalled and replaced due to the health “crisis” generated by the incident, which apparently referred to a breakdown in rules and procedures for controlling the pandemic. Although the KCNA report did not provide details about the breakdown and did not mention any active COVID-19 cases that resulted from the incident, pundits in South Korea and elsewhere speculated that confirmed cases had occurred. Three weeks later, the WHO and New York Times scoreboards still reported no confirmed cases or deaths.31

An unexpected conclusion for me and my colleagues, after studying documents from WHO and other sources, including the reports concerning the crisis during late June 2021, is that the report of zero cases and zero deaths is plausible. This conclusion has resulted from the observations in multiple publications from WHO and the DPRK that provide frank and detailed information about the country’s public health problems and accomplishments, including major achievements in addressing infectious diseases. The track record of Dr. Salvador and other staff members at WHO’s country office and elsewhere also gives no reason to doubt WHO’s reports about COVID-19 in the DPRK. In short, the DPRK may lead the world in the fight against COVID-19.

But as in most other countries, addressing the upstream causes of pandemics like COVID-19 has not made it into the DPRK’s publicly announced priorities. During the Japanese imperial period terminating at the end of the Second World War and then during the Korean War, the Korean peninsula experienced massive deforestation. As noted already, the ROK recently has made some progress in reforestation. Under Kim Jong-un, the DPRK officially has embarked on reforestation efforts, but progress has been slow, partly due to the continuing use of wood as fuel for heating and cooking, especially in rural areas.32 Industrial production of meat has not advanced to nearly the level in the ROK, let alone China, although the government has set goals to increase meat supplies to address the chronic problem of nutritional deficiencies. Unlike China and South Korea, the DPRK’s unique approach to socialist policy-making has not provided an opening for multinational capitalist agricultural corporations, so the march toward factory farms that breed pathogens causing pandemics has not occurred, at least not yet. Nevertheless, like the ROK and most other countries, capitalist or not, the DPRK’s approach to controlling the COVID-19 pandemic has not explicitly addressed its upstream causes in habitat destruction and industrial agriculture.

The Undiscovered Holy Grail of COVID-19

The two Koreas—sharing a language, cultural traditions, history of imperial conquest and war, and interrupted family connections—both have mostly succeeded in controlling the pandemic, within different political-economic systems and with markedly different methods. South Korea has used sophisticated technology, a disciplined public health labor force, efforts to prevent economic collapse by avoiding lockdowns, and financial help with social support services. Its approach to communication emphasizes transparency and helpfulness through messages from government and public health officials at the federal, provincial, county, and municipal levels. The economy remains capitalist, but the welfare state includes a health care system that fosters universal access, minimal financial barriers, and little capitalist orientation to corporate profit making.

North Korea, with a unique approach to socialism rooted in the Juche principle of self-sufficiency and strong leadership, has cut off transmission of infection from other countries by closing its borders very early and imposing strict quarantine procedures. While the country has suffered some economic decline due to lost trade relationships coupled with continuing financial sanctions by the United States and United Nations, a lockdown has occurred only briefly, affecting a single city. Public-sector employment has continued, preventing additional financial crises affecting the population. Private profit-making corporations do not take part in its economy or health care system, a system that has achieved higher numbers of health professionals and better health outcomes than many countries of Asia. Among North Korea’s openly acknowledged public health problems, hospitals and clinics remain underfinanced and undersupplied, largely due to external economic sanctions. Probably recognizing its inability to provide adequate clinical services during a pandemic, the government has acted aggressively to prevent cases leading to wider transmission.

Despite success in controlling the pandemic’s downstream effects in illness and death, the countries have taken no actions to address the root causes of emerging pandemics in habitat destruction and production of meat. Partly as a result, they, like most other countries, remain vulnerable to future pandemics that may be worse than this one.

Clarifying the best ways that countries can prevent both the downstream effects and upstream causes remains an undiscovered holy grail of COVID-19. The successes of the two Koreas and the different methods underlying these successes may offer some clues. Avoiding the destructive effects of capitalist structures and processes within health care and public health systems is one. Leadership that focuses on how to provide economic protection and adherence to public health interventions is another. Then there is the subtle impact of respect for cultural traditions like Juche in the north and, in the south, looking at cherry blossoms in springtime.

Notes

  1. Editors, “Happy Birthday, Paul!,” Monthly Review 51, no. 11 (April 2000).
  2. Howard Waitzkin, “Confronting the Upstream Causes of COVID-19 and Other Epidemics to Follow,” International Journal of Health Services 51, no. 1 (2021); Rob Wallace, Alex Liebman, Luis Fernando Chaves, and Rodrick Wallace, “COVID-19 and Circuits of Capital,” Monthly Review 72, no. 12 (May 2020): 1–15; Rob Wallace, Dead Epidemiologists: On the Origins of COVID-19 (New York: Monthly Review Press, 2020).
  3. For this and other Fulbright fellowships, I have wondered how I could have gotten selected, given my constant criticisms of U.S. foreign policies. I can imagine the vetting of my application in a meeting between an assistant of my recent boss, Mike Pompeo, and the CIA agent who vets Fulbright applicants:
    • Pompeo’s assistant: “I don’t think we should accept this guy. He’s opposed basically every U.S. foreign policy since he was a teenager.”
    • CIA agent: “No, I disagree with you. I think we should select him. He’ll give people an impression that U.S. encourages freedom of speech and a range of opinions, and obviously he’s completely harmless.”
  4. South Korea Military Expenditure,” Trading Economics, January 2021; Kim Jae-won, “Korea Worst in Income Inequality in Asia-Pacific,” Korea Times, March 16, 2016; Justin McCurry, “South Korea’s Inequality Paradox: Long Life, Good Health and Poverty,” Guardian, August 2, 2017; Steven Denney, “Piketty in Seoul: Rising Income Inequality in South Korea,” Diplomat, November 4, 2014; “State of Income Inequality in South Korea,” Borgen Project, March 3, 2020; “Shocking Results Show South Korea Has the Highest Suicide Rate Among the OECD Countries,” Allkpop, September 21, 2020; “Suicide Rates,” OECD Data, 2019.
  5. Erica Wertheim Zohar, “Quarantining in Korea: One Young American’s Unique Travel Adventure During the Covid-19 Pandemic,” Forbes, July 10, 2020.
  6. Reports about ambitious epidemiological work in South Korea include: Shin Young Park, Young-man Kim, Seonju Yi, et al., “Coronavirus Disease Outbreak in Call Center, South Korea,” Emerging Infectious Diseases 26, no. 8 (2020); Young Joon Park, Young June Choe, Ok Park, et al., “Contact Tracing During Coronavirus Disease Outbreak, South Korea, 2020,” Emerging Infectious Diseases 26, no. 10 (2020); Seungjae Lee, Tark Kim, Eunjung Lee, et al., “Clinical Course and Molecular Viral Shedding Among Asymptomatic and Symptomatic Patients with SARS-CoV-2 Infection in a Community Treatment Center in the Republic of Korea,” JAMA Internal Medicine 180, no. 11 (2020): 1447–52.
  7. Park, Choe, Park, et al. “Contact Tracing During Coronavirus Disease Outbreak, South Korea, 2020.”
  8. Oliver Johnson and Tinashe Goronga, “Why Communities Must Be at the Centre of the Coronavirus Disease 2019 Response: Lessons from Ebola and Human Immunodeficiency Virus in Africa,” African Journal of Primary Health Care & Family Medicine 12, no. 1 (2020): a2496.
  9. Coronavirus Disease-19, Republic of Korea,” Central Disaster Management Headquarters and Central Disease Control Headquarters, December 25, 2020.
  10. Coronavirus World Map: Tracking the Global Outbreak,” New York Times, accessed July 19, 2021.
  11. PHM Korea Statement on COVID-19 Outbreak and Responses in South Korea,” People’s Heath Movement Korea, March 19, 2020.
  12. Choe Sang-hun, “Delivery Workers in South Korea Say They’re Dying of ‘Overwork,’” New York Times, December 22, 2020.
  13. Saerom Kim, Jin-hwan Kim, Yukyung Park, Sun Kim, and Chang-yup Kim, “Gender Analysis of COVID-19 Outbreak in South Korea: A Common Challenge and Call for Action,” Health Education & Behavior (2020).
  14. On deforestation and reforestation in South Korea, see: Hilary Allison, “The Fall and Rise of South Korea’s Forests,” Quarterly Journal of Forestry 110, no. 1 (2016); “ASTER: The Ultimate 2018 Winter Olympics,” U.S. Geological Survey and NASA Earthdata, February 21, 2018; Connor Cowman, “Deforestation of Sacred South Korean Forest Represents Worldwide Problem,” Horizon, December 14, 2017; Justin McCurry and Emma Howard, “Olympic Organisers Destroy ‘Sacred’ South Korean Forest to Create Ski Run,” Guardian, September 16, 2015; Hans Nicholas Jong, “South Korea Trading Giant Vows Zero Deforestation in Papua Palm Oil Operation,” Planetary Press, March 6, 2020.
  15. Regarding meat production, imports, and consumption in South Korea, see: Pete Olson, Yong Keun Ban, and Sunyoung Choi, There’s the Beef (and Pork)! U.S. Red Meat Success in South Korea (Washington DC: USDA Foreign Agricultural Service, Global Agricultural Information Network, 2018); “Masterplanning of a Modern Meat Production Facility in South Korea,” NIRAS, January 2021; Qiuhong Wang, Anastasia N. Vlasova, Scott P. Kenney, and Linda J. Saif, “Emerging and Re-emerging Coronaviruses in Pigs,” Current Opinion in Virology 34 (2019): 39–49.
  16. Jan Douwe van der Ploeg, The New Peasantries: Rural Development in Times of Globalization (London: Routledge, 2018); Jan Douwe van der Ploeg, “Peasant-Driven Agricultural Growth and Food Sovereignty” (Food Sovereignty: A Critical Dialogue, International Conference Paper 8, New Haven, Yale University, September 14–15, 2013). For orientations toward peasant agriculture and educational materials from throughout the world, see: La Via Campesina (International Peasant’s Movement); Food First; Eric Holt-Giménez, A Foodie’s Guide to Capitalism (New York: Monthly Review Press, 2017); Alexander Liebman, Tammi Jonas, Ivette Perfecto, et al., “Can Agriculture Stop COVID-21, -22, and -23? Yes, but Not by Greenwashing Agribusiness,” Pandemic Research for the People, December 15, 2020; Maywa Montenegro de Wit, “What Grows from a Pandemic? Toward an Abolitionist Agroecology,” Journal of Peasant Studies, December 14, 2020.
  17. Fidel Castro Ruz, “The Two Koreas—Part 1,” Monthly Review, July 22, 2008; Fidel Castro Ruz, “The Two Koreas—Part 2,” Monthly Review, July 24, 2008.
  18. World Health Organization, Country Cooperation Strategy: Democratic People’s Republic of Korea, 2014–2019 (New Delhi: World Health Organization, 2016). For a systematic review of the limited public health research regarding North Korea, see: John J. Park, Ah-young Lim, Hyung-soon Ahn, et al., “Systematic Review of Evidence on Public Health in the Democratic People’s Republic of Korea,” BMJ Global Health 4, no. 2 (2019).
  19. Kim Il-sung, “On Eliminating Dogmatism and Formalism and Establishing Juche in Ideological Work,” December 28, 1955, available at marxists.org.
  20. Choe Sang-hun, “North Korea Tells Its People to Stop Smoking. But What About Kim Jong-un?,” New York Times, November 5, 2020.
  21. James L. Schoff and Feng Lin, “Making Sense of UN Sanctions on North Korea,” Carnegie Endowment for International Peace, 2018; Justin McCurry and Agencies in Seoul, “North Korea: Kim Jong-un Says Economic Plan a Near-Total Failure at Rare Political Meeting,” Guardian, January 6, 2021.
  22. Mijin Lee, Hannah Kim, Danbi Cho, and So Yoon Kim, “Overview of Healthcare System in North Korea,” Journal of the Korean Medical Association 56, no. 5 (2013): 358–67.
  23. Hani Kim, Florian Marks, Uros Novakovic, Peter J. Hotez, and Robert E. Black, “Multistakeholder Partnerships with the Democratic Peoples’ Republic of Korea to Improve Childhood Immunisation: A Perspective from Global Health Equity and Political Determinants of Health Equity,” Tropical Medicine & International Health 21, no. 8 (2016); Towards Sustainable and Resilient Human Development: Strategic Framework for Cooperation between the United Nations and the Democratic People’s Republic of Korea 2017–2021 (Pyongyang: Office of the Resident Coordinator, 2016); “Sri Lankan President, DPRK Get WHO Public Health Excellence Award,” World Health Organization, September 5, 2016.
  24. DPR Korea, Timor-Leste Eliminate Measles, Six Countries in WHO South-East Asia Achieve Rubella Control,” World Health Organization, August 2, 2018; Elimination Measles: A Look at How Democratic People’s Republic of Korea Did It (New Delhi: World Health Organization, 2018); “World Health Organization in Democratic People’s Republic of Korea,” World Health Organization, accessed July 16, 2021; Towards Sustainable and Resilient Human Development.
  25. In this and later paragraphs, I try to synthesize the mostly low-quality reporting about North Korea’s responses to the pandemic, such as: Kate Ng, “Coronavirus: North Korea Orders Construction of ‘Crucial’ New Hospital While Still Claiming No Cases,” Independent, March 19, 2020; Tom O’Connor, “North Korea Announces Release of All but Three Foreigners in Coronavirus Quarantine,” Newsweek, March 20, 2020; Vincent Koen and Jinwoan Beom, “North Korea and the Coronavirus Pandemic,” OECD Ecoscope, April 10, 2020; Joshua Berlinger, Paula Hancocks, and Yoonjung Seo, “North Korea’s Covid-19 Response Has Been a ‘Shining Success,’ Kim Jong Un Claims,” CNN World, July 3, 2020; Choe Sang-hun, “North Korea Declares Emergency After Suspected Covid-19 Case,” New York Times, July 25, 2020; Kim Tong-hyung, “North Korea Lifts Lockdown in City, Rejects Flood, Virus Aid,” Yahoo! News, August 14, 2020; Hyung-jin Kim and Kim Tong-hyung, “Mired in Crises, North Korea’s Kim to Open Big Party Meeting,” SFGATE, December 28, 2020; Mitch Shin, “What Is the Truth About COVID-19 in North Korea?,” Diplomat, January 6, 2021. Other unsubstantiated claims in the media have included accounts of quarantine facilities as prison camps; the DPRK’s requests for vaccines as inconsistent with its reports of no COVID-19 cases; North Korean hacking into organizations developing vaccines; and the DPRK’s initiative to develop its own vaccine as an attempt to enhance its arsenal for biological warfare.
  26. WHO reported that 64 primary contacts of the suspected Kaesong case and 3,571 secondary contacts were quarantined in state-run facilities for forty days. Kim, “North Korea Lifts Lockdown in City, Rejects Flood, Virus Aid.”
  27. “World Health Organization in Democratic People’s Republic of Korea.”
  28. WHO Representative to the Democratic People’s Republic of Korea,” World Health Organization, accessed July 19, 2021.
  29. Democratic People’s Republic of Korea Situation,” World Health Organization, accessed July 16, 2021.
  30. “Coronavirus World Map: Tracking the Global Outbreak.”
  31. Justin McCurry, “North Korea Covid-19 Outbreak Fears After Kim Jong-un Warns of ‘Huge Crisis’ in ‘Antivirus Fight,’” Guardian, June 30, 2021; Kim Tong-hyung and Kim Hyung-jin, “How Bad Is the COVID-19 Pandemic in North Korea? Here’s What We Know,” Los Angeles Times, June 30, 2021; “Kim Jong-un: North Korea Sees ‘Grave Incident’ After Covid Lapses,” BBC News, June 30, 2021.
  32. Jean Chemnick, “North Korea Faces an Environmental Crisis,” Scientific American, April 19, 2019; AFP in Le Bourget, “North Korea Launches ‘War on Deforestation,’” Guardian, December 8, 2015; “Deforestation in North Korea,” NASA Land-Cover and Land-Use Change Program, accessed July 16, 2021; James Pearson and Seung-woo Yeom, “Fake Meat and Free Markets Ease North Koreans’ Hunger,” Reuters, November 3, 2017.
2021, Volume 73, Number 4 (September 2021)
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