North Korea Appears to Have Managed Its COVID-19 Outbreak: What Comes Next?

Despite widespread concern that a COVID-19 outbreak in North Korea would be devastating, given the country’s weak health care system, limited access to medical equipment, supplies and medicines, and widespread malnutrition, Pyongyang appears to have stabilized the recent outbreak in record time with minimal deaths, at least according to the official government narrative. While North Korea seems to have avoided drastic outcomes this time around, its anti-epidemic efforts came at high economic and social costs, and the largely unvaccinated population remains a concern to global efforts to combat this virus. Building the country’s capacity to deal with epidemics and health crises should be part of a global health strategy to prepare for future pandemics.

Background

Since the World Health Organization (WHO) first declared COVID-19 to be a pandemic on March 11, 2020, the Democratic People’s Republic of Korea (DPRK or North Korea) claimed to have zero domestic cases until only recently. On May 12, 2022, the country officially reported its first confirmed COVID-19 case and declared a nationwide emergency.

This admission raised concerns in the global community about Pyongyang’s ability to manage the situation for three key reasons.

• First, the weak state of the country’s health care system. According to the Global Health Security Index, North Korea ranks third-to-last in the world in regard to its ability to respond to a pandemic. It was widely believed that the system would be quickly overwhelmed by an uncontrollable surge in cases.
• Second, there is no concrete evidence that North Korea has begun vaccinating its population, despite multiple offers of vaccine assistance from the international community.
• Third, the vast majority of North Koreans have long been suffering from malnutrition and, thus, have weakened immune systems. This may increase their vulnerability to viral infections and further complications.

Despite these challenges, however, the DPRK has claimed victory over the country’s outbreak just three months after its first case was reported. While there are still lingering questions about how data was collected during the outbreak and how accurately the government reporting reflects realities on the ground, the official narrative demonstrates the regime’s strong confidence that it has the situation under control.

Assessing the Impact of the COVID-19 Outbreak in the DPRK

There is little available data that accurately portrays the current COVID-19 situation of North Korea. In fact, the only source is the national reports that are published daily by the government-run Korean Central News Agency (KCNA).

One reason to question the data is that only the number of fever cases have been reported, as opposed to the number of actual confirmed COVID-19 cases, which could be due to the country having a low testing capacity. Since June 1, 2022, the number of fever cases has been consistently decreasing until it reached zero on July 29, 2022. Moreover, while almost 20 percent of the population has fallen ill with fever-related symptoms to date, the number of deaths has been incredibly low (74 officially to date), with a case-fatality rate of 0.0016 percent. It is noteworthy that Johns Hopkins University has reported the lowest case-fatality rate for confirmed COVID-19 cases in Bhutan at 0.035 percent. Other countries that have been considered successful in their COVID-19 response with vaccination rates above 80 percent, such as Singapore, South Korea and New Zealand, reported 0.1 percent.

While it remains difficult to accurately assess the DPRK’s current COVID-19 situation, state media reports indicate that North Korean society appears to have resumed regular activity. Less than three weeks after the May 12 announcement, government officials loosened lockdown restrictions, and large-scale projects, such as rice transplantation and residential construction projects, have continued. Contrary to the concerns of the international community, the impact of COVID-19 does not appear to have been catastrophic, and it would seem that North Korea has been able to stabilize its spread.

How Did North Korea Respond?

In order to understand how North Korea has been able to control the virus, it is important to recognize its long-standing commitment to public health. North Korea’s health care system is founded primarily on preventative medicine, making disease monitoring and prevention the priority. As such, during the COVID-19 outbreak, local doctors and medical students were tasked with visiting 200-300 homes per day to facilitate disease surveillance.

Based on state media reporting about the pandemic responses, it appears that the North Korean government’s stewardship of the response to the outbreak has been effective and efficient. They declared a national emergency immediately after the first confirmed COVID-19 case, ordered a nationwide lockdown, and delivered medicine and food to houses while promoting the production of domestic medicine. State media has also reported the case numbers and provided medical information about COVID-19 daily.

With limited geographic mobility and domestic migration even before the pandemic, North Korean society is set up in a way that makes controlling the transmission of this airborne virus easier than in most countries. In short, North Korea was able to quickly stop community spread through aggressive public health measures, and as such, has not experienced a catastrophic situation. Furthermore, the first reported COVID-19 case was said to have been of the Omicron variant, which while more contagious, is less severe than the original virus or other variants.

What Limitations of the Country’s Health care System Did the Virus Expose?

However, despite these accomplishments, there are significant limitations within the DPRK’s health care infrastructure to deal with this or future epidemics. Although the nation has a history of success in mass vaccinations, few, if any, COVID-19 vaccines are known to have been administered. Insufficient supply of diagnostic kits and therapeutic medicines have led fever patients to seek treatments that tend to be merely palliative, such as some forms of traditional medicine.

The number of epidemiological studies undertaken in the country and analysis of data gathered remains unknown. More detailed data is necessary to adequately analyze North Korea’s COVID-19 experience and ability to effectively control the virus. Recently, for instance, Pyongyang announced its theory about the exact location and pathway of the first COVID-19 infection case. Despite concluding the first infections occurred when two people came into contact with “alien things in a hill,” the report did not provide any actual evidence, such as testing these objects for the virus.[1]

Attention needs to be given to non-pandemic-related public health concerns as well. While the entire country was making an effort to contain the virus, a different outbreak of waterborne diseases occurred in Haeju City in South Hwanghae Province. Waterborne infectious diseases remain common in North Korea due to its inadequate infrastructure for providing clean water. The accumulation of multiple infections and outbreaks can easily overwhelm the country’s health care system and complicate treatment.

How Will North Korea Respond in the Future?

The North Korean government appears to have gained confidence in its anti-epidemic strategy after achieving effective control over the first wave of COVID-19 infections. It is highly likely that for future epidemics, they will continue the same tried-and-true approach of total lockdown and government-led resource mobilization, such as prioritizing epidemic control over all social activities, the maximum utilization of health care workers, increasing medicine production and mobilizing the military to directly serve the people. Since the government controls all aspects of national production and spending in North Korea, resource mobilization can be achieved more easily than in other countries where private interests from various sectors often conflict.

At this point in time, the North Korean government has shown very limited indication of pursuing assistance from the global community for COVID-related aid, which would include requests for large quantities of vaccines. Its hesitancy towards accepting vaccines is reflected in its rejection of multiple offers of AstraZeneca and China’s Sinovac from the COVAX program.

Those who have experienced hardship together tend to develop a higher sense of unity. This concept partially explains how North Korea has avoided collapse over the past decades when going through economic crisis, famine and natural disasters. Just as South Koreans gave the ruling Democratic party a large majority of the seats in the national assembly in the 2020 general election acknowledging the government’s impressive performance in managing the pandemic, the successful response against the first wave of COVID-19 in North Korea is likely to strengthen the relationship between the government and its people.

Questions still remain regarding the future of North Korea’s disease containment strategy and its adjustability, such as what might happen when a new variant is introduced. Key lessons and takeaways from the pandemic could be distilled into its next National Health Priorities report.

What Can the Global Community Do?

Understanding North Korea’s current public health status can inform approaches to providing it with effective health assistance.

While North Korean requests for COVID-19 vaccinations are unlikely, the global community should be ready to support vaccination efforts if Pyongyang decides to seek aid. Despite its refusal of outside help, North Korea has previously demonstrated that it is highly capable of implementing national vaccination programs. The North’s 2007 measles vaccine campaign, which was a collaborative effort with UNICEF, WHO and Gavi, is one such example. At the height of that campaign, North Korea was able to vaccinate a daily average of 3.3 million people for three consecutive days. Support measures for vaccinations would include determining the type of vaccines needed, evaluating and maintaining the cold chain, and providing technical and logistical support to prepare and implement vaccination campaigns.

The pandemic revealed the DPRK’s limited epidemiological capabilities, causing the country to isolate itself from the rest of the world for more than two years. As global health is only as strong as the weakest health system, helping North Korea build capacity in epidemiology and disaster response should be part of a global strategy to be better prepared for future pandemics. Since North Korea has not been willing to accept offers of bilateral assistance from the US or South Korea over the past few years, these countries may want to consider channeling their assistance via the UN and other multilateral organizations in the future. One possible example of multilateral cooperation is through the WHO vaccine hub network. In June 2021, WHO nominated the first technology transfer hub so that the recipients of low- and middle-income countries can access specialized training to locally produce mRNA vaccines. The nomination went to South Africa, which collaborated with Afrigen to aid 15 countries in their vaccine education. In February 2022, the WHO announced South Korea as the biomanufacturing hub for WHO. It remains to be seen if North Korea will be willing or able to participate in this program.

Conclusion

North Korea’s pandemic success story makes one thing clear, despite its lack of resources, the country has been able to withstand the pandemic on its own terms thus far. While it seems capable of successfully battling pandemics in its own way, the past three months have exposed the country’s reliance on low-tech public health measures, e.g., border closures and lockdowns, fever as a proxy for infection, and crude epidemiological methods. Further, its attitude of overcoming the health crisis exclusively in its own way prevents international cooperation, and in turn, weakens global health security. To prevent a repeat of these conditions in the future, the international community should consider a multi-year health assistance package for North Korea that includes COVID aid, health system strengthening, and humanitarian aid as a way to bolster pandemic prevention and response capabilities.

1. [1]

   “Route of COVID-19 Inroads Verified in DPRK,” Rodong Sinmun, July 1, 2022.