Cablegate: North Korea Struggles with Shortage of Medicine And


DE RUEHUL #0881/01 1210153
P 300153Z APR 08





E.O. 12958: N/A

REFS: A) 07 SEOUL 1080
B) SEOUL 499


1. (SBU) Famine, natural disaster, mismanagement, a lack of safe
drinking water, and shortages of essential drugs and vaccines have
left the population of the Democratic Peoples' Republic (DPRK)
vulnerable to infectious diseases, despite the existence of an
adequately-trained corps of medical personnel in the regime's
four-tiered state medical system. The most troublesome infectious
diseases currently include tuberculosis, malaria, hepatitis B,
diarrheal diseases, and intestinal parasites. The looming food
shortages in North Korea will likely further aggravate the disease
burden of the population. If relations between the United States
and the DPRK improve, and if North Korean authorities become more
open to outside humanitarian aid, the infectious disease problem in
the DPRK could provide the United States with numerous opportunities
(beyond existing projects) to reach out to the North's public by
providing drugs, vaccines, diagnostic equipment, and other
much-needed health-related aid. End summary.

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2. (SBU) Dr. Karl A. Western, MD, DTPH, Senior International
Scientific Advisor at the National Institute of Allergy and
Infectious Diseases (NIAID -- part of NIH), spent four weeks in
November 2007 in Embassy Seoul as an Embassy Science Fellow (ESF --
see ref A), examining infectious disease management in the
Democratic People's Republic of Korea (DPRK). He gathered
information from Republic of Korea (ROK) government sources,
ROK-based non-governmental organizations (NGOs) active in the DPRK,
and international NGOs and organizations. The goal was to provide
U.S. policymakers with a detailed snapshot of the DPRK public health
sector, as well as to outline possible avenues for enhanced U.S.
health-related cooperation with the DPRK, should our relationship
improve as the denuclearization process proceeds.

3. (U) The project focused on four essential issues: A) the
infectious disease situation in DPRK; B) the capability of the DPRK
health system to diagnose and manage current endemic infectious
disease as well as potential infectious disease threats; C) existing
efforts by NGOs and other donors to increase the DPRK capacity to
deal with infectious diseases; and D) unmet needs creating
opportunities that U.S. assistance could potentially address. The
following is Dr. Western's report.


4. (U) Prior to beginning the Embassy fellowship, Dr. Western and
Dr. Boris Pavlin, MD, MPH, a Johns Hopkins University Preventive
Medicine Resident at NIAID, conducted an extensive review of public
information available on the Internet on infectious diseases in
DPRK. They also conducted interviews with U.S. Government (USG)
agencies and organizations active in the DPRK. In Seoul, Dr.
Western met with officials from the Ministry of Health and Welfare
(MOHW), the Ministry of Unification (MOU), international
organizations active in DPRK, and ten of the 20 ROK-based NGOs with
health programs in DPRK.

5. (SBU) Official data from the DPRK Government on infectious
diseases are incomplete, unverifiable, and may be biased by
political considerations. North Korea reports few infectious
diseases to the World Health Organization (WHO) and other
international organizations. Multiple sources indicated that
effective infectious disease surveillance and reporting do not exist
in North Korea. Furthermore, the lack of microbiological and
serological diagnostic laboratories results in an inability to
confirm suspected diseases, and therefore in substantial
underreporting. DPRK sensitivity also prevents external
organizations from verifying reported figures or independently
evaluating infectious disease conditions. The DPRK also does not
report on a number of important infectious diseases. In those
circumstances, if the disease is endemic in border areas of
neighboring countries such as ROK, China, and Russia, it is
reasonable to assume that the DPRK is infected with the pathogen or
at risk of becoming so.


6. (U) The DPRK Government established 14 health priorities in its
2004-2008 Five Year Plan. Tuberculosis, malaria, and HIV/AIDS
ranked first. Other infectious diseases (hepatitis B, intestinal
infectious diseases and parasitoses) were ranked second.


7. (U) There was a dramatic increase of reported tuberculosis
during the past decade as a result of the overall deterioration in
the population's nutritional status, deterioration of the public
health infrastructure, scarcity of medicines, and increased
attention given to the problem. The DPRK has had a long-term
commitment to tuberculosis treatment and control through its
vertical National Tuberculosis Program (NTP). There are currently
approximately 67 district tuberculosis care facilities
(second-level) and 13 hospitals dedicated exclusively to the
isolation and care of tuberculosis patients.

8. (U) With technical assistance from the World Health Organization
(WHO), the DPRK initiated Directly Observed Therapy Program,
Short-Course (DOTS) in 1998 with a three-phased expansion to cover
the country by 2004. As a result, DOTS coverage has approached 100%
and DOTS case detection has increased from two percent before 1998
to 108% (sic) in 2004. In 2004, there were 52,591 cases diagnosed
and treated under DOTS with successful treatment rates ranging from
88% to 94%, compared with a 76% success rate from non-DOTS
treatment. According to official DPRK statistics, in 2005, incident
(new and relapsed) cases of tuberculosis totaled 42,722
(178/100,000), with 3,015 deaths (13/100,000), and with a prevalence
rate of 179/100,000 population. (For comparative purposes, the 2005
official incidence rate per 100,000 population was 96.4 in South
Korea, and 4.5 in the United States.) Multiple drug-resistant (MDR)
tuberculosis accounted for 2.8% of new cases in North Korea's
official statistics, and 15% of previously treated cases in 2004.
The DPRK tuberculosis program is currently supported by the World
Bank Global Development Finance Program, the Global Fund to Combat
AIDS, Tuberculosis and Malaria (GFATM), and donations from multiple

9. (SBU) Tuberculosis is the most important infectious disease
among DPRK defectors arriving in South Korea, and the incidence

among defectors is suggestive of a much higher infection rate, and
of a much higher incidence of drug resistance, than are reflected in
the North's official statistics. In a 2004 study of arriving
defectors, 42 cases of tuberculosis (88% pulmonary) were diagnosed,
giving an extrapolated incidence of 900 cases per 100,000
population. Nine tuberculosis isolates were tested for drug
resistance: four were isoniazid (INH)-resistant, three were MDR, and
only two were susceptible to all primary tuberculosis drugs.

10. (U) Major ongoing challenges in the area of tuberculosis
treatment include sustaining and expanding DOTS throughout the
country; improving tuberculosis diagnosis (Gram stain, X-ray, sputum
culture, drug-sensitivity testing); ensuring the availability of
primary tuberculosis drugs and secondary drugs for MDR cases; and
shifting tuberculosis care from isolation facilities to ambulatory


11. (U) Although the fact was never certified by WHO, the DPRK was
considered free of indigenous malaria from the 1970's to 1998, when
Plasmodium vivax reemerged in human populations on both the north
and south sides of the Demilitarized Zone (DMZ). To date,
indigenous malaria in North Korea has been exclusively P. vivax with
no confirmed resistance to chloroquine. Mefloquine, however,
appears to be the most commonly administered drug, often without the
addition of an appropriate drug (e.g. primaquine) to eliminate the
hepatic stage of the parasite to prevent relapses. Endemic malaria
continues to be largely confined to the DMZ, but potential mosquito
vectors occur throughout the country below 2,000 meters. The press
reported malaria outbreaks in Pyongan Namdo Province in 2006
following monsoon-related heavy rainfall.

12. (U) In response to the malaria epidemic, DPRK and WHO
established a Malaria Control Program in 1999. The number of
officially-reported cases surged to 295,570 in 2001, but by 2006 the
number reported dropped to 9,300. According to the latest detailed
reports (2003), only 26% of cases were confirmed by peripheral blood
smear. Malaria reports among children (962 cases) and pregnant
women (92 cases) were relatively low. No hospital malaria deaths
were reported. During that same year, WHO reported that 0.7% of
deaths in children less than 5 years old were attributed to malaria
infection. Dr. Western could find no information about mosquito
vector ecology and epidemiology and was told that the DPRK considers
this a sensitive issue. (In contrast, the ROK has conducted
epidemiology and vector biology studies of vivax malaria south of
the DMZ. This information is available in peer-reviewed
publications and in reports of the Korea Center for Disease Control
and Prevention (KCDC).)

13. (U) The DPRK malaria control program relies upon the
distribution of donated permethrin-impregnated bed nets, treatment
of clinical cases, and prophylaxis of high-risk populations such as
the military and civilian populations along the DMZ. In 2003, 90,360
new bed nets were sold or distributed, and 394,000 bed nets were
treated or retreated with insecticide. No data were available on
total malaria drug donations.

14. (U) Ongoing challenges include increasing the percentage of
confirmed malaria cases through peripheral blood smear examination,
more appropriate treatment of malaria cases to prevent relapse,
maintaining the availability and use of appropriate anti-malarial
drugs, sustaining the bed net program, and a better understanding of
malaria epidemiology in North Korea to develop scientifically-based

prevention and control strategies.


15. (U) North Korea denies the existence of HIV infection and
clinical AIDS cases. The United Nation AIDS Agency (UNAIDS)
estimated (2004) that there were fewer than 100 cases in the
country. DPRK HIV/AIDS surveillance consists almost entirely of
screening blood donors, foreign visitors and returning North
Koreans. In 1988, the DPRK issued a Public Health Directive on
HIV/AIDS, usually an indication that there is an actual or real
threat. In October 2003, the Ministry of Public Health organized
the first national HIV/AIDS workshop.

16. (U) To date, only one DPRK defector has tested HIV positive and
his infection may have been acquired in a transit country.

17. (U) While the level of HIV infection is currently extremely
low, DPRK is at risk from the disease due to unsafe medical
injection practices, decreased blood screening due to economic
constraints, and increased population movements both within the
country and to third countries, such as China, where HIV prevalence
is increasing.

Hepatitis B

18. (U) Hepatitis B Virus (HBV) is usually transmitted by dirty
needles, during sexual intercourse, or from mother to newborn. The
majority of patients infected with HBV eventually clear the
infection, but a minority becomes chronically infected. In addition
to morbidity from the acute infection, HBV is a major cause of liver
failure and liver cancer in chronically-infected HBV surface antigen
positive (HBsAg+) individuals. Infection with Hepatitis B Virus
(HBV) is one of the DPRK's biggest public health problems, but no
country-wide data are available on its overall prevalence. Outside
the WHO Expanded Program on Immunization (EPI), which targets
infants under one year of age, HBV vaccine is not widely available
in the DPRK. According to the Eugene Bell Foundation (EBF), only
about 10% of newborns born to HBV-antigen-positive mothers become
infected. HBV diagnostic testing is not routine, but patients who
present with jaundice are isolated in hepatitis care facilities in
district (second-level) clinics until they die or recover.
Antiviral treatment for HBsAg+ patients is not available.

19. (U) The best HBV data available come from a baseline serosurvey
conducted by the Ministry of Public Health and the EBF in 2004 in
Wonsan, a northeast coastal city, in advance of a school-based pilot
immunization program. Wonsan authorities told EBF that there are
approximately 800-1,000 new cases each year in a population of about
310,000, a prevalence of 6-7% in adult populations, and 7-8% HBV
antigen+ in pregnant women. The serosurvey of school children aged
7-10 years old found an HIV antigen+ prevalence of 33%. This cohort
of school children was born before HBV was incorporated into the EPI
immunization program. Independently, the U.S. Centers for Disease
Control and Prevention (CDC) assesses DPRK as "highly endemic" for
HBV with HBsAg+ prevalence above 8%.

20. (SBU) A study of DPRK defectors by South Korea's Ministry of
Health showed an anti-HBsAg antibody rate of 83.9%, an indication of
nearly universal exposure to the virus at some time in life, and a
HBsAg+ rate of 15.4%.

21. (U) HBV is a vaccine preventable disease. Ongoing challenges

are to institute a universal immunization program for newborns and
school entrants to complement the existing EPI effort, and to
deinstitutionalize the care of patients with jaundice attributed to

Diarrheal Diseases

22. (U) Diarrhea is caused by person-to-person spread, non-potable
drinking water, failure to wash hands, contaminated food, unsanitary
latrines and sewage, and poor hygienic practices. Poor nutrition is
a contributing factor to intestinal diarrhea. Many intestinal
bacteria and viruses and a few one-cell parasites (e.g. amoeba,
giardia, cryptosporidia) cause acute and chronic diarrhea. Current
microbiological techniques can identify the cause of infectious
diarrhea in about 80% of cases. North Korea lacks diagnostic
laboratories, so the infectious agents causing diarrhea in
individual patients or causing epidemics in communities are unknown.

23. (U) Diarrhea continues to be the most common cause of childhood
illness and hospitalization in DPRK. An October 2002 nutritional
assessment revealed that 20% of young children had had diarrhea
within the two weeks preceding the survey. This rate was similar to
the findings of an earlier nutritional survey in 1998. According to
the survey, most DPRK mothers (78.4%) were aware of diarrheal
symptoms and indications for referral to a health center. The
majority (90.9%) of DPRK children with diarrhea received
WHO/UNICEF-recommended home treatments (e.g. oral rehydration
solution or rehydration fluids), but few (17.9%) increased their
fluid intake and continued eating.

24. (U) The DPRK Ministry of Public Health (MOPH) has initiated
disease surveillance in two pilot counties (Icheon-gun, Gangwon
Province and Pyongsan, Hwanghae Bukdo Province), and reported
increases in the numbers of diarrhea cases from mid-August to
mid-September 2007 of 45% and 36% respectively. The epidemic
investigation should now be completed and the MOPH may eventually
share the results with WHO and other partners. WHO is currently
awaiting approval of the proposed National Disease Surveillance
Report Project.

Acute Respiratory Infections

25. (U) Acute respiratory infections, along with diarrheal
diseases, are the most common causes of infant morbidity and
mortality in developing countries. In a 2000 nutritional survey,
the DPRK Government reported that 12.2% of children under five years
of age had had an acute respiratory infection in the two weeks prior
to the survey. A reported 82.7% of those children were seen by a
health care provider.

26. (U) Seasonal influenza undoubtedly occurs in DPRK but no
information is reported. DPRK suffered an outbreak of H7N1 (not
H5N1) avian influenza in chickens in March 2005. No human cases were
reported. No suspected cases of Severe Acute Respiratory Syndrome
(SARS) have been reported.

Intestinal Parasites

27. (U) Most intestinal parasitic infections are caused by Soil
Transmitted Helminths (STH) such as ascaris (roundworm), tricuris
(whipworm), and hookworm. The DPRK has had a strategic plan to

reduce STH infections through twice-yearly community deworming. As
a result, roundworm and hookworm prevalence decreased to 5.0% and
0.1% by the 1980's. Since then, natural disasters, economic slumps,
limited water supplies, and improper handling and use of "night
soil" have led to wide-spread environmental contamination and
increased STH rates. In 2003, the situation reached a low point when
only 38 of 2,679 primarily schools dewormed only 14,180 children out
of an eligible population of 3,110,620 (0.5%). DPRK conducted a
national STH Survey in 2004. The overall prevalence of infection
with one or more soil helminth was 42.6%. Roundworm infection was
most common (41.1%) and had the highest rates of moderate/severe
infection (4.6%) followed by whipworm (27.0%/1.0%) and hookworm
(0.3%/0.0%). According to the 2007 UN Children's International Child
Emergency Fund (UNICEF) Action Plan, almost 97% of DPRK children
aged two-five years of age will receive deworming tablets this year.

28. (U) Intestinal parasite surveys of DPRK defectors found one or
more intestinal parasites in 28.9% of them, with the highest rate
occurring among teenagers (44.8%). This second figure is remarkably
similar to the 42.6% intestinal parasite rate found in the survey of
school children in North Korea.

Recent Infectious Disease Outbreaks

29. (U) The Good Friends Center for Peace, Human Rights, and
Refugees and other NGOs have reported endemic leprosy, high
prevalence of head lice and skin infections (tinea and boils),
epidemics of measles, scarlet fever, cholera, typhoid fever,
paratyphoid fever, hemorrhagic fever, severe hepatitis with liver
failure, and tuberculous meningitis among children in military
households. (There have also been outbreaks of foot and mouth
disease among animals, with a potentially severe economic impact,
but the disease does not affect humans directly.)

30. (U) The DPRK Government has not recognized or reported any of
the above conditions except for measles. Prompt recognition and
accurate diagnosis of infectious disease epidemics in DPRK are
severely hampered by the secrecy and sensitivity of the Government,
and by the virtual absence of microbiologic diagnostic laboratories.
Compounding these obstacles is the North's unwillingness to share
specimens for diagnosis outside the country. The diagnosis of
leprosy, head lice, tinea, and boils can be made by a trained
clinician, but most of the other diseases reported by Good Friends
require laboratory confirmation to be certain of appropriate

31. (U) The practical effect of these unsubstantiated reports is
that donor organizations and NGOs have offered drugs and supplies to
DPRK that may be inappropriate or harmful. Scarlet fever is not
affected by measles vaccination and penicillin does not affect the
clinical course or spread of measles.

Vaccine Preventable Childhood Diseases

32. (U) The DPRK participates in the WHO Expanded Program on
Immunization (EPI), which is designed to provide infants with
primary vaccination coverage during the first year of life. MOPH
and WHO partners include UNICEF, the Global Alliance for Vaccines
and Immunization (GAVI), and NGOs (including the South Korean Red
Cross). Vaccines are distributed from the national level to the
provinces for administration at the county level. Each province is
assigned an immunization day each month when immunization is

provided at the local level. Prior to the immunization day, section
doctors remind households with infants requiring vaccines to attend
the clinic. Individual vaccinations are recorded in Child Health
Care Cards which remain at the local clinic unless the family moves
elsewhere. Newborns are vaccinated against tuberculosis (BCG
vaccine) by the attending midwife or physician whether at home or in
an institution.

33. (U) Official DPRK records indicate relatively high infant
immunization rates: 1) BCG: 94% (2004); 2) Measles: 95% (2004); 3)
Diphtheria-Pertussis-Tetanus-times 3 (DPT3): 79% (2005); 4)
Hepatitis B Vaccine-times 3 (HBV3): 92% (2005); and Poliomyelitis
times 3 (Polio3): 97% (2005). HBV vaccines were introduced in 1997.
Historical review indicates that coverage with the other EPI
vaccines has substantially improved over ten years ago. GAVI has
independently verified the reliability of these figures (including
the relatively low DPT3 coverage) through an audit of Child Health
Care Cards at the local level.

34. (U) A review of DPRK reporting of vaccine preventable childhood
diseases indicated that the EPI Program is very effective overall.

- BCG/Tuberculosis. BCG vaccine confers significant protection
against primary tuberculosis infection in infants and children, but
has little or no effect on infection and disease in adults. There is
anecdotal reporting by NGOs that pediatric tuberculosis is
increasing, but there are no well-done studies on this subject.

- Measles. On April 20, 2007, a WHO Press Release reported the
first measles outbreak in DPRK since 1992. The epidemic occurred in
30 of the 204 counties in DPRK and caused the deaths of two adults
and two infants. The DPRK Government reported that 9% of cases
occurred in children under the age of five years and 40% in 11-19
year-olds. In response to the epidemic, the DPRK distributed 16
million doses of donated measles vaccine. Measles immunization
before one year of age does not protect approximately 30% of infants
and re-immunization at 18-27 months is necessary to achieve
protection of school children at the 95%-plus level. Re-immunization
at school entry or in young adulthood is necessary to convey
life-long protection. Information on the percentage of cases from
one-four years of age is lacking, but the measles epidemic pattern
is consistent with failure to administer a booster dose of measles
vaccine and to re-immunize upon school entry, rather than a failure
of the EPI Program.

- Diphtheria. The last reported diphtheria cases in DPRK were
reported in 1981. Re-immunization with adult diphtheria-tetanus
(dT) vaccine is necessary to maintain life-long protection.

- Pertussis (Whooping Cough). Pertussis has persisted in the DPRK.
In 2006, DPRK reported 409 cases with no deaths. Pertussis
immunity following DPT3 lasts several years. Booster doses are
required at school entry to maintain immunity through adolescence.
The age breakdown of reported cases would be needed to assess the
effectiveness of the EPI Program.

- Tetanus. North Korea has reported no cases of tetanus since
1998, when six neonatal cases were reported. Immunity to tetanus
immunization lapses after 10-15 years. Booster immunizations are
required to maintain immunity during childbearing years and
adulthood. Neonatal tetanus occurs when unvaccinated mothers give
birth to infants under unsanitary conditions and the newborn is
infected with tetanus spores. No figures were found on the
percentage of pregnant women immunized against tetanus.

- Hepatitis B. Immunity against HBV lasts three to five years,
depending on the vaccine product administered. Re-immunization is
required at school entry and during adulthood to ensure continued

- Poliomyelitis. The DPRK participates in the WHO Poliomyelitis
Eradication Program and has not reported a case of paralytic
poliomyelitis since before 1980. As part of the WHO Program, the
DPRK has reported and investigated 63 cases of acute flaccid
paralysis (AFP), none of which was caused by wild poliomyelitis
infection. It is not known how many (if any) of the AFP cases were
due to adverse effects of the live poliomyelitis vaccine.
Immunization with oral trivalent poliomyelitis vaccine (OPV) three
times during infancy requires one booster dosage to convey life-long

- Other Vaccine Preventable Diseases. DPRK does not routinely
immunize against Haemophilus influenzae type B (Hib - also called
bacterial meningitis), rubella (German measles), mumps, or varicella
(chicken pox). These diseases are not routinely reported by DPRK.

Sexually-transmitted Diseases

35. (U) North Korea does not report sexually-transmitted diseases
(STDs). Serologic testing for syphilis is available in Pyongyang,
and there have been rumors of syphilis outbreaks during the past ten
years. No seroprevalence studies have been done. The ROK
Government and NGOs working in the DPRK have noted that, while there
is no organized or sanctioned commercial sex in DPRK, food shortages
and famine have resulted in women practicing cottage-industry
commercial sex work to save themselves and their families.

36. (U) Among female defectors, there have been a total of 137
cases of STDs since the testing program was begun in 2004. The
annual number of STDs remained between 28 and 35 from 2004-2006, but
jumped to 45 in the six months through June 2007. This may be a
true increase, or be due to an increased number of female defectors,
to an expansion of STD testing, or to other factors. Since most
STDs (syphilis being an exception) have incubation periods in days
and many defectors were sexually abused or practiced commercial sex
in transit countries, it is difficult to determine where they
acquired the STD.

Hemorrhagic Fever with Renal Syndrome

37. (U) Hemorrhagic Fever with Renal Syndrome (Hantavirus/Korean
Hemorrhagic Fever - HFRS) is caused by members of the bunyavirus
family first recognized in Korea during the Korean War among UN
military personnel. DPRK reported 316 cases of HFRS from 1961-1997
when reporting stopped. Since mice are the reservoir for the virus
and spread the infection through urine and feces, increases in mouse
populations and/or lapses in rodent control and increased
human-rodent contact may result in human cases. Note: There are
numerous anecdotal reports of North Koreans capturing and eating
rodents to survive, especially in prison camps. The looming food
shortages will likely make this phenomenon more widespread,
increasing the risk of hantavirus infection. End note.)

Japanese Encephalitis

38. (U) Japanese Encephalitis (JE), the most common cause of viral
encephalitis in Asia, is endemic on the Korean Peninsula. JE is

transmitted by Culex mosquitoes; wild birds are the natural host,
and domestic pigs are reservoirs for the virus. South Korea has
largely controlled JE through immunization programs and the
reduction of human-pig interaction. North Korea does not routinely
immunize against JE. The International Vaccine Institute (IVI) in
Seoul launched a pilot program in February and March this year,
immunizing two cohorts of 3,000 children each in Nampo and Sariwon
(municipalities west and south, respectively of Pyongyang) against
JE and Hib (bacterial meningitis). IVI will follow up to assess
safety and efficacy in the DPRK setting.

Rickettsial Diseases

39. (U) Scrub typhus (Orientia tsutsugamushi) and murine typhus
(Rickettsia typhi) are endemic to the region, but no data are
available because these are not notifiable diseases and due to a
lack of laboratory diagnostic capability.

Other Parasitic Diseases

40. (U) The June 2007 issue of the Korean Journal of Parasitic
Diseases reported on an ELISA test serological survey of 137 DPRK
citizens resident along the China border and 133 female defectors
resident in ROK, testing for Clonorchis sinensis (lung fluke),
Taenia solium (pork tape worm, the causative agent of
cysticercosis), and Sparganum, a second cestode parasite. Among the
270 specimens tested, 11.5%, 9.3%, and 4.1% tested positive for
immunoglobulin G (IgG) to the antigens of these specific parasites.
Overall, 38.2% of men and 15.8% of women were positive to one or
more of these pathogens. The results suggest that these parasites
may be highly prevalent in some areas of DPRK. Paragonimiasis (lung
fluke) was once common on the Korean Peninsula and entered into the
differential diagnosis of tuberculosis. The Korean Institute of
Tuberculosis reports that this disease is very rare in ROK and has
not been found in DPRK defectors.


41. (U) North Korea, in contrast to most developing countries,
possesses an organized four-level healthcare system. It is staffed
at the first, or local, level with "quasi-physicians" who receive
three years of medical training and who are responsible for the
medical care of 200 families. Primary care, health education, and
prevention programs are carried out at the local level. Although
the first-level primary facilities suffer severely from lack of
electricity, heating, basic equipment, and drugs or vaccines,
indications are that they are usually staffed by dedicated,
hard-working, and resourceful health staff who try to make the best
of the circumstances.

42. (U) Second-level (district) clinics provide basic medical care
and tuberculosis and hepatitis resident care. Third-level
(provincial) hospitals provide both ambulatory and inpatient care.
Fourth-level national and specialty hospitals are located primarily
in Pyongyang and provide health services to members of the elite.
Comparatively speaking, Pyongyang-based health facilities are better
staffed and equipped than those at the provincial, district, and
local level, but shortages of electricity, fuel, safe water
supplies, refrigeration, functional diagnostic equipment,
microbiological laboratories, vaccines, and medications exist
throughout the system. Essential drugs (including antibiotics) are

usually not available within the health system and must be obtained
by the patient in the open or "black" market. The sources and
quality of these drugs are open to question.

Obstacles to the Provision of Care

43. (U) The absence of electrical power at the first-level
healthcare facilities, and intermittent or fluctuating power at
secondary, tertiary and national facilities, have a profound impact
on the ability to run both basic equipment (e.g. refrigerators,
microscopes, X-ray machines) and more sophisticated medical devices.
The recent announcement of a USD 4 million USAID Energy Assistance
Program, to provide generators at rural and peripheral health
clinics through U.S.-based NGOs, will help address this obstacle.
The money will be disbursed in two tranches of USD 2 million each.

44. (U) The scarcity and low quality of fuel in the DPRK may be a
limiting factor in efforts to combat the shortage of electricity by
providing generators. During the frequent interruptions to
electrical power, generators may be used intermittently or only when
there is the need to run a diagnostic test. This practice will not
only adversely affect the storage of vaccines and medicines that
require refrigeration, but may damage the equipment.

45. (U) Urban areas of North Korea had urban water supplies and
sewage systems, but these facilities have deteriorated to the point
where sewage contamination of water supplies is frequent, and many
hospitals are without reliable running water regardless of
potability. Frequent hand-washing is the critical feature of
effective infection control in the hospital and clinic setting.
Rural areas usually do not have potable water or sewage disposal.

46. (U) With the exception of the EPI and blood banking in the
Pyongyang area, DPRK does not have access to disposable needles,
infusions, surgical equipment, or disposable gloves. As a result of
the lack of electricity and water, needles, syringes, and equipment
are either chemically disinfected or reused with multiple patients.

47. (U) A "cold chain" is essential for the successful execution of
immunization programs as well as for proper storage of many
infectious disease diagnostic kits and most injectable antibiotics.
Multiple sources indicate that there is no functional "cold chain"
or reliable refrigeration in DPRK. In a broader sense, the lack of
refrigeration will have an impact on food safety and food-borne

infectious diseases.

Obstacles to Reliable Diagnoses

48. (U) First-level clinicians usually do not have thermometers,
stethoscopes, blood pressure cuffs, or microscopes. Without
thermometers and microscopes, it is not possible to confirm febrile
conditions for referral, let alone diagnose specific pathogens.
Tertiary level and central hospitals also lack X-ray machines
(relying instead on dangerous fluoroscopy) and supplies such as
X-ray plates. Maintenance and repair of existing or donated
equipment is a serious problem.

49. (U) In all his research and interviews, Dr. Western was unable
to identify a single functioning general or specialized microbiology
diagnostic laboratory anywhere in DPRK. Most infectious diseases
cannot be diagnosed without serological and/or microbiological
confirmation. Recent examples in North Korea are the fact that 75%
of malaria cases are not confirmed by peripheral blood smear, and

recent epidemics of scarlet fever and measles could not be confirmed
because of a lack of diagnostics. At present, limited numbers of
tuberculosis specimens from the DPRK are being cultured and tested
for drug susceptibility in South Korea, but the DPRK does not seem
to be connected to various WHO Collaborating Centers and other
diagnostic and reference networks.

A Strength -- Human Capital

50. (SBU) The DPRK's greatest strength in infectious disease
management and public health is its health infrastructure, which
reaches to the community and family level. The IVI reports that
members of the DPRK Academy of Medicine with whom they collaborate
are extraordinarily well-read and up-to-date on the medical
literature, but have had no opportunity to apply or practice the
latest advances and developments in infectious diseases diagnosis,
prevention, or control. There are three teaching hospitals in
Pyongyang, but once again the training is largely theoretical.
North Korea has an adequate supply of fully trained
"quasi-physicians" to meet its citizens' needs, but does not pay
them or provide them with drugs or vaccines to practice their
profession. As usual in a system relying on "quasi-physicians," the
nursing profession is under-represented (MD/RN ratio of 1:1) and
under-utilized. The consensus among NGOs active in the DPRK is that
medical and nursing staffs are knowledgeable at all levels about
medical care. However, several NGOs, including EBF, indicated that
the understanding of sanitation and antisepsis was frequently
lacking or inadequate.

Treatment and Immunization Programs

51. (U) There is a major effort through WHO and NGOs to maintain a
DOTS program to treat tuberculosis in DPRK. A second treatment
program is the recently rejuvenated Soil Transmitted Helminth (STH)
school-based deworming program. Other treatment programs such as
penicillin therapy for strep throat are frustrated by the lack of
microbiologic culture and antibiotics (i.e. penicillin). The STH
Program may provide a framework or template to establish a school
immunization program to provide booster vaccination in follow-up to
the EPI Program.

52. (U) The DPRK is completely dependent on external procurement
and donations for the vaccines used in the EPI. The DPRK is not
capable of producing any vaccines at the present time or in the
foreseeable future. On the other hand, as a socialist country with
a healthcare system penetrating to the local (200 family) level, the
DPRK is in a position to educate and mobilize families to
participate in public health activities. The monthly Immunization
Day in the EPI Program is a successful example of this approach.
EPI must be supported and sustained, but it is focused only on
infants under one year of age. EPI's goals are in danger of being
undermined by inadequate attention to pre-natal care (nutrition, HBV
serology testing, tetanus toxoid), newborn programs (HBV
vaccination), and vaccine boosters upon starting school.

----------------------- ----------------------
----------------------- ----------------------

53. (U) U.N. agencies, particularly WHO and UNICEF, have
long-standing assistance programs in North Korea. The DPRK is
dependent upon these and other international organizations for the
most of their essential drugs and vaccines. While the DPRK

Government health priorities are disease-specific, the top WHO
technical assistance program priorities include: 1) disease
prevention and control; 2) vaccines and immunization; 3)
evidence-based health policies and health care (clinical guidelines,
rational drug use); 4) strengthening basic health services at the
community level; 5) medical education and updating of health
personnel technical skills; 6) blood safety; 7) strengthening
technical and research capacity in public health and epidemiology;
8) health system development; 9) tobacco control; and 10) increasing
MOPH capability to partner.

54. (U) There are several U.S.-based NGOs that are active in the
DPRK, most notably the EBF (which also has a base in Seoul),
Samaritan's Purse, Mercy Corps, and Global Resource Services. EBF,
in particular, has been very active in combating tuberculosis in the

55. (U) According to the ROK-based NGO Anum International, there are
55 South Korean NGOs providing assistance to the DPRK. Twenty of
these NGOs are operating in the health sector. During his ESF
period in Seoul, Dr. Western met with ten of these organizations: 1)
Anum International; 2) Eugene Bell Foundation (EBF); 3) Foundation
for Inter-Korean Medical Cooperation (FIKMC); 4) "Good Friends"
Center for Peace, Human Rights, and Refugees; 5)"Good Neighbors"
International; 6) "Join Together" Society (JTS); 7)Korean Health
Industry Development Initiative; 8) the Korean Institute of
Tuberculosis (KIT); 9) the Korean Medical Association (KMA); and 10)
the Korean Red Cross.

56. (U) With the exception of KMA and KIT, the organizations that
Dr. Western consulted are humanitarian assistance organizations in
which health is one of several program areas. Except for "Good
Neighbor" and "Join Together", the NGOs' international humanitarian
experience was limited to North Korea. Many of the NGOs had medical
and/or public health advisors, but only KMA had medical leadership
with clinical expertise in clinical and laboratory diagnosis or the
medical management of infectious diseases.

57. (U) Typically the ROK-based NGOs respond to requests from the
DPRK Government. At least in the initial years of their
relationship, there is little or no opportunity to negotiate and
modify the request, determine the field site or point of delivery
(usually Pyongyang), or verify the delivery and use of the
donations. (See ref B for an analysis of the difficulties faced by
South Korean NGOs trying to work in North Korea.)

58. (U) The MOU indicated that it has no formal coordinating body
for the many ROK-based NGOs active in the DPRK, but Anum
International indicated that it is currently the lead agency in an
informal health network that meets quarterly (and as needed) to
exchange information and coordinate efforts. Similar informal
networks exist among NGOs assisting with agriculture and emergency
response. Because of their broad mission, many NGOs participate in
more than one network. The MOU also has an NGO consultative body
that meets quarterly.

59. (U) Some bilateral donors, such as the Italian government, are
involved in efforts to strengthen healthcare and improve healthcare
facilities in the DPRK.


60. (SBU) There are several potential areas where the U.S.

Government could consider providing health-related humanitarian or
technical assistance, if the future evolution of the U.S.-DPRK
relationship leads to deeper U.S. engagement there.

- Electrical Power. First steps have been taken by the recent
award by USAID of the first tranche (USD 2.0 million) of a USD 4
million program to provide generators to first-level health clinics.
The award was given to four U.S.-based NGOs. If successful, this
program could be expanded. Provision of electrical power is crucial
to the proper storage of drugs and vaccines, light microscopy, and
the operation of X-ray machines, medical equipment, and surgical
suites. Gasoline- or diesel-powered generators may be difficult to
sustain. Consideration should be given to low-technology solar
generators to provide core services.

- Potable Water. The availability of potable drinking water is
critical to the prevention of diarrhea and other water-borne
diseases. Consideration should be given to the provision of
chlorination tablets and educational programs to use them. A second
approach would be a program to construct tube wells along with
provision for maintenance.

- Microbiological Diagnosis. Short of establishing a central
microbiological and reference laboratory in Pyongyang, the U.S.
could consider providing infectious disease diagnostic kits to
provincial and district healthcare facilities for the diagnosis of
bacterial and viral diseases of public health importance (e.g.
tuberculosis, influenza, hepatitis, typhoid fever, and measles).

- National Immunization Program. The DPRK national immunization
program is one of the few functional public health programs at the
present time. A major drawback of the program is that it focuses on
the immunization of infants before the age of one year. The
epidemics of vaccine preventable diseases that DPRK is experiencing
are due to infections in older children who have not received
booster immunizations. The U.S. could consider sponsorship of a
school-entry immunization program providing booster doses of
pediatric vaccines.

- Tuberculosis. The Eugene Bell Foundation, a U.S.- and South
Korea-based NGO, is the major player in providing technical
assistance and support to tuberculosis diagnosis and treatment in
the DPRK. Eugene Bell is also one of the four U.S.-based NGOs
participating in the USAID electric generator project. The U.S.
National Institutes of Health (NIH) have received an invitation from
the Eugene Bell Foundation to develop a tuberculosis research
component to ongoing and planned activities.

- Hepatitis. There are licensed vaccines against hepatitis A virus
(HAV) and hepatitis B virus (HBV). HBV vaccine could be
incorporated into NIP for infants and school-entry programs.

- Intestinal Parasites. DPRK has a functional school deworming
program. Roundworm and hookworm are among the infections recognized
in the new U.S. Neglected Tropical Diseases Initiative. The U.S.
could consider including the DPRK in the Initiative.

- Training. DPRK physicians, nurses, and biomedical scientists have
been isolated from advances in medicine and public health for sixty
years. While medical and nursing students are trained to provide
good care, they are not provided with the scientific basis of
medical practice. They also suffer severely from lack of access to
diagnostic tools, drugs, and prevention products. The USG could
explore offering refresher training for medical and academic leaders
on-site or through distance learning. USG agencies such as the

Centers for Disease Prevention and Control (CDC) and the National
Institutes of Health (NIH) could be approached to lead this effort.


61. (SBU) Health conditions in the DPRK will deteriorate further
as the looming food shortages strain immune systems. U.S.
humanitarian aid will need to be focused on nutrition in the short
term. For the longer term, should the evolution of the U.S.-DPRK
relationship lead to deeper U.S. engagement with North Korea, the
U.S. will find numerous options in the health sector for reaching
out to the North Korean public in ways that could have a lasting
impact. End comment.


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