North Korea is widely perceived as a nuclear threat to the international community, but what if imposing economic sanctions on North Korea actually meant that we were inadvertently inflicting a threat on global health security? More than 23 million people of North Korea currently face regular famines, intermittent or no power supply, and environmental destruction from flooding events that have ultimately cultivated a public health ‘hotspot’ of infectious diseases for pathogens that are transmitted by water and indoor air. Among these pathogens, the five major infectious diseases are Tuberculousis (TB), acute respiratory illnesses, diarrheal diseases, SARS, and Avian Flu - with TB posing the largest threat.
TB is an airborne bacterial infection that is highly contagious with each infected person transmitting TB to 10 - 20 new people. TB is highly lethal, and 50% of untreated victims are killed. North Korea has established its polices on self-sustenance, in what is referred to as Juche philosophy, and has supported the development of a universal health care system that was rather effective prior to the collapse of the socialist economy in the 1990s . However, a reduction in financial solvency due to a culmination of extreme weather conditions, a 50% decline in GDP between 1990-2000 to $463 per capita, and an increase in economic sanctions have contributed to the deterioration of the health system. As a result, TB began to re-emerge in North Korea in the mid-1990s, and the World Health Organization (WHO) estimated in 2010 that the proportion of North Korea’s population with TB is 399 per 100,000 people from 38 per 100,000 people in 1994.
Despite the drastic increase, notifications of TB have begun to slightly decline in the past several years due to the WHO supported DOTS program which tests and treats 87% of TB patients successfully with antibiotics. However, 17% of TB cases in North Korea are multiple drug resistant TB strains, thereby posing a large concern for global health specialists in preventing and treating TB both in North Korea and the spread of TB into the international community that are untreatable. In 2008, a team of health experts from Stanford University developed North Korea’s first drug-resistant tuberculosis diagnostic lab bringing hope to the fight against TB .
Acute respiratory illnesses (ARI), such as pneumonia, can also be transmitted by air and are caused either by bacteria or viruses. ARIs are one of the leading causes for children under-5 mortality rates in North Korea, accounting for more than 20% of all causes of death under-5 with a rate of 55 per 1000 live births that is higher than both the regional and global rates. Approximately 12% of all children under-5 exhibit symptoms, and challenges in preventing disease include harsh winters and malnutrition, which especially compromises the immune system amongst young children .
Almost every year, North Korea faces devastating floods that damage essential crops that are needed for sustenance and have resulted in food insecurity for the nation . The increase in flooding events have been attributed to food and energy shortages, which have lead to deforestation for the conversion of forest into agricultural lands, logging, and energy . Afforestation efforts are a crucial step towards achieving food security and mitigating the deleterious impacts on water infrastructure.
Although it is reported that 96% of the population have access to an improved water source, 82% to an improved drinking water source and 99.2% adequate excreta disposal, financial instability and natural disasters have rendered the majority of this infrastructure faulty. This has induced a high prevalence of diarrheal diseases and malnutrition. The combination of diarrheal diseases and malnutrition is another leading cause of death for children under the age of five, particularly outside Pyongyang. Diarrhea accounts for 12% of all deaths under the age of five. A focus on maternal and child nutrition and health are important for combating preventable diseases, but also rely on broad improvements for food security, nutrient supplementation, and improvements on water infrastructure.
The US Department of State has issued a report on Global Water Security highlighting that within the next decade, water problems- shortages, poor water quality, or floods “will contribute to instability in states important to US national security interests”. Building the local capacity to prevent flooding events, promoting agricultural R&D, and repairing faulty water infrastructure are far more effective policies than offering food aid that takes months to arrive after a famine event and is blasphemous to Juche philosophy.
Perhaps it is the humility of our vulnerability that should unite us to seek compassion with our enemies so that we are enabled to combat the invisible army that threatens all of humanity.
 World Health Organization (2009) WHO Country Cooperation Strategy: Democratic People's Republic of Korea.
Accessed from: http://www.who.int/countryfocus/cooperation_strategy/ccs_prk_en.pdf
 World Health Organization (2013) Accessed from: https://extranet.who.int/sree/Reports?op=Replet&name=/WHO_HQ_Reports/G2/PROD/EXT/TBCountryProfile&ISO2=KP&outtype=html
 Accessed from: http://news.stanford.edu/news/2010/february22/tb-north-korea-022510.html
 Accessed from: http://news.bbc.co.uk/2/hi/asia-pacific/6947230.stm
 Myeong, S. and Hong, H.J. (2009) Developing Flood Vulnerability Map for North Korea. Accessed from: http://www.asprs.org/a/publications/proceedings/baltimore09/0068.pdf
 Director of National Intelligence (2012). Global Water Security. Accessed from: http://www.dni.gov/files/documents/Special%20Report_ICA%20Global%20Water%20Security.pdf