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North Korea, or the Democratic Peoples Republic of Korea, it is officially called, one of the most controversial states in modern society. Despite presenting itself as a completely self-sufficient socialist state, it has been declared a totalitarian dictatorship, built around the all-pervasive cult of personality of the ruling Kim family.
A 2014 report on the state of human rights in North Korea has increased the controversy even further, reporting violations on a level beyond that of any other country in the modern world (World Report 2015: North Korea, 2015)
All of this is supported by high levels of state propaganda and control, which aim to obscure the actual state of things from both insiders and outsiders. Naturally, this has affected the state of medical care as well. The existing research points to low standards of health and health care and high mortality in the population but often relies on data coming from the state, which puts its validity into question.
The lack of specific information is related to the reason this country was chosen for this paper. North Korea is one of the most secretive countries in the world, and they are very manipulative about the information they release. This makes efforts to assess the actual state of healthcare in this country both very difficult, and very notable in academia.
There is very little data on the total number of physicians and nurses, as well as the current number of clinics and hospitals, with the some of the most recent information dating to 2003, or being related from defectors escaping out of the country.
These factors are the reasons why on the one hand this country is rightfully on the list with the highest mortality rate in this country is so high and, on the other conducting research on the matter is so difficult.
The purpose of this paper is to study the available information about the state of health care in North Korea, in order to gain an unbiased view of the situation, as well as determine the role of nursing in the country.
Geography
North Korea is located in the northern part of the Korean Peninsula, in East Asia. It is bordered by three countries: South Korea, China, and Russia. It is a mountainous country, with almost 80 percent of the territory consisting of mountain ranges and hills, with the remaining 20 percent being composed of large lowland valleys, with large coastal plains in the east and the west (North Korea Geography, n.d.).
The geographical location creates appropriate conditions for a combination of humid continental and oceanic climate, with warm, but rainy, summers, and cold winters. The climate also creates dangers to the well-being of the population by making the country vulnerable to typhoons, droughts, and floods (World Weather & Climate Information, n.d.).
Together with rampant deforestation and subsequent soil erosion, with other ecological issues brought upon by mismanagement of resources, these issues have a profoundly negative effect on the state of the population, contributing to the already present problem of food shortages.
Population
While the information coming from the official institutions of North Korea has a history of not being very reliable, the 2008 Census of the populace has shown rather starkly poor results concerning the health and demographics of the nation.
At the time of the census, the country was reported to have a population of 24.1 million and is mostly homogeneous in terms of race, with a small percentage of ethnic Chinese and Japanese. It has one of the highest population densities in the world, with approximately 1,267 people per square mile.
Compared to the beginning of the 1990s, the census showed a drop in the quality of health and nutrition, in large part due to several famines which ravaged the country between 1995 and 2000, causing from 600,000 to 1,000,000 deaths. The life expectancy has also declined, with 65.6 years for men and 72.7 from women. Additionally, the census showed a large percentage of infant mortality, at about 19.3 child deaths per 1,000 live births, and high numbers of maternal mortality, with 77.2 maternal deaths per 100,000 live births. However, these numbers are notably higher in Western research.
The census notes high numbers of populations as having received an education and sees the adult population predominantly married. Also, about a third of the nation is involved in agriculture.
Finally, the data points to bad housing conditions with numerous issues, which include lack of heating, and flush toilets, small percentages of electricity use of household chores (Haub, 2010)
Government
Despite democratic elections held at regular intervals, the results are predetermined to keep the members of the Kim family in power, with the leader having the power of a totalitarian dictator. The political management is based on the loyalty to the family, which gives the regime similarities with absolute monarchy. It is a one-party system, with the Workers Party of Korea having full legal authority over any other parties.
The first leader of the country, Kim Il-sung, was the supreme leader for 46 years until his death in 1994 and has been written into the constitution as the Eternal President , while the highest post in the government was shifted to the chairman of the National Defense Commission, a position held by the grandson of Kim Il-sung, Kim Jong-il. He remained in that position until his death (and was posthumously granted the title of an Eternal Chairman of the National Defense Commission ), after which he was succeeded by Kim Jong-un (The World Factbook: Korea, North, 2016).
Economy
From its establishment in 1948, the county was heavily dependent on the economy of the USSR. With its support, it was able to prosper for several decades, particularly in contrast with South Korea, which was suffering from internal political turmoil and crises. However, after the fall of the Soviet Union, the North Korean economy collapsed, forcing it to open up to the global market, despite its policy of self-sufficiency. Despite this, the country has been on a decline, with South Korea having a gross national in being 42.6 times larger than Norths as of 2013, and consistently underperforms in trade compared to the South.
The country is suffering from chronic levels of food insecurity and malnutrition, with more than 70 percent of the population suffering from these issues (The World Factbook: Korea, North, 2016).
According to the Wall Street Journal, the countrys economy suffers from a lack of established property rights, private foreign trade, reliable currency, or big data to help its businesses (Eberstadt, 2015).
State of Health
While local institutions attempt to paint a positive image of the health system, the reality is much grimmer. Medical care has deteriorated to the point where methamphetamines are prescribed instead of expensive medicine coming from China. A lot of the more complex equipment is not fixed when broken due to lack of skill, and reports from defectors who have escaped the country state that rather than risk using the state hospitals, many citizens prefer self-medication (Ramani, 2016).
The country is suffering from food and medical supplies shortages, lack of domestic pharmaceutical production, a deteriorating sanitation system, high numbers of infectious diseases, and high populace mortality.
Data aggregated by the World Health Organization shows that in 2008 only 6% of the government spending went into healthcare.
Culture/Traditional Medicine
Due to dilapidated healthcare, traditional medicine is very popular in the country. It includes treatment with the herbal medicine, acupuncture, meditation, aromatherapy, by using essential plant oils, and the more ritualistic practice of moxibustion, which relies on the application of heat with special traditional implements
Healthcare System and Delivery Include
Governmental health-related agencies and health regulatory organizations
Healthcare in North Korea includes a universal medical service and health insurance, with the government presenting itself as the primary provider and regulator of healthcare, with the Ministry of Public Health being the principal regulatory organization. The preventive healthcare and disease regulation and oversight is carried out by the Central Hygiene and Anti-Epidemic Institute. However, the sickness surveillance system is underdeveloped and ineffective (World Health Organization, 2009).
There is some conflicting information about the actual state of the medical care agencies and regulators in the reports by the World Health Organization and by Amnesty International, which described the health-related agencies, and the healthcare in general, in the of nigh-collapse, based in interviews with North Korean escapees (North Korea 2015/2016, 2016). WHO heavily criticized the bleak depiction of North Korean healthcare in the Amnesty International report as outdated, even though it was supported by individual reports (Aid agencies row over North Korea health care system, 2010).
This caused the organization to be criticized in turn by a number of media outlets, which pointed out North Korea maintains strict control over which areas of the country foreign non-government organizations can visit, and the WHO and the other UN organizations do not have free reign to check anywhere they would like (Schaefer, 2010).
Healthcare personnel and hospitals
The lack of officially released data makes the situation difficult to accurately estimate, but in the 1990s the number of hospitals was 2,401 and there were 5,655 clinics in the country. The creating of new institutions has stagnated since then, not in the least due to government-supported shift towards traditional medicine.
The data provided by North Korean defectors points to a decrease in the number of nurses, and an overall low level of skill of young medical practitioners. The statistics website Knoema points to nursing and midwifery density of 41 staff members per 10,000 as of 2003, based on data gathered by WHO (World Health Organization, n.d.).
The nursing education system and accrediting organizations
Again, the collection of data on the nursing education system in North Korea is quite difficult and can be supported by few, if any, recent sources. The 2001 article Nursing Education in North Korea: Past 50 Years and Future described the nursing education on medical colleges as a three-year course, however, there were also 6-month training courses in the hospitals (Yi, 2001). The article predicted that little if any development of nursing education was to be expected due to the economic depression the country had found itself in.
The WHO Country Cooperation Strategy , published in 2009, for the Democratic Peoples Republic of Korea shed some light on the educational system, by pointing out that too much focus was placed on knowledge acquisition, in detriment to practice acquisition, resulting in outdated and ineffective practices.
A more recent study has only served to reiterate the uncertainty, together with the fact that the specific requirements and standards of the educational system, curriculum, and the length of education have changed repeatedly in the past years (Lee, 2016).
Nursing Associations
Further reinforcing the poor state of healthcare in the country, North Korea is not a member of any nursing associations and does not have any outside standards of medical service imposed upon it, leaving a lot of freedom for violation of human rights and denial of quality health service.
Health Priorities
The data collected, despite some gaps, clearly shows that healthcare is not a very strong priority in North Korea at this point in time. The facilities are in terrible condition, and nursing education does not seem to function according to a set system of regulations and tends to fluctuate. While the country boasts free medical care for all its citizens, this serves as little more than propaganda material, due to the low quality of service, and the frequently anticipated gifts of food and money, which can determine the level of healthcare practitioner involvement and the final quality of the of care.
Due to the secretive nature of the country, existing data is hard to validate, and international organizations, like the World Health Organization, have little influence on it.
The number of medical practitioners is very low, although the bigger cities supposedly offer a better picture.
The level of preventive medicine is also low, as is signified by large numbers of death from contagious diseases.
Conclusion
Before the nurses and the nursing profession will be able to make any lasting impact on the national well-being, the healthcare system ends educational services would need to undergo drastic changes, with much larger percentages of the state expenditures allocated to it.
However, the policies of the current government do not seem to support such reforms, which means that improvements are unlikely.
References
Aid agencies row over North Korea health care system. (2010).
Eberstadt, N. (2015). How North Korea Became the Worlds Worst Economy. The Wall Street Journal.
Haub, C. (2010). North Korea Census Reveals Poor Demographic and Health Conditions.
Lee, Y. S. (2016). Medical Education and Certification of Physicians in North Korea. Korean Medical Education Review, 18(1), 16-20. Web.
North Korea Geography. (n.d.).
Ramani, S. (2016). North Koreas Public Health Campaign.
Schaefer, B. (2010). United Nations Defends North Korean Health Care System.
The World Factbook: Korea, North. (2016). Web.
World Health Organization. (n.d.). The Democratic Peoples Republic of Korea Nursing and midwifery personnel density. Web.
World Health Organization. (2009). WHO Country Cooperation Strategy. Web.
The democratic Peoples Republic of Korea. Web.
World Report 2015: North Korea. (2015).
World Weather & Climate Information. (n.d.).
Yi, G. M. (2001). Nursing Education in North Korea: Past 50 Years and Future. Journal of Korean Community Nursing, 12(2), 437-449.
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