Author’s Response to: Two Koreas and public health: ‘First, do no harm’

Abstract

I thank Dr Shin for his interest in my editorial ‘Two Koreas, war and health’1 and for raising important issues on the potential impact of economic sanctions and the use of humanitarian aid for political leverage on the health and human rights of the North Korean people.2 It is noteworthy that recent economic sanctions against North Korea were made while people in the country were still suffering from lingering food shortages and economic difficulties. During the North Korean food crisis in the mid and late 1990s, about 240 000–600 000 people died due to the crisis, based on estimates using the North Korean census data of 1993 and 2008.3,4 Infant and under-five mortality rates increased about two-fold during the period.4 Biological imprints of the severe food shortage remained in North Korea until recently, according to a study on the long-term trends in childhood underweight prevalence.5 Considering that food aid from the World Food Programme was associated with improved nutritional indicators in a North Korean nutrition survey,6 economic sanctions and other political measures to reduce food aid might have caused health problems, especially among the most vulnerable North Korean people. Economic sanctions are like a siege on a city and may precipitate long-term sequelae. Epidemiological studies have provided evidence of long-term health effects associated with sieges, as was the case in the Dutch famine during World War II.7,8 Infant mortality, a measure for early life conditions, showed a seven-fold difference in 2010 between the two Koreas.1 Anthropometric data indicated a substantial difference in height between the children of the two Koreas.9 As a result, in the reunified Korea of the future, health and social inequalities according to prior citizenship will be inevitable. Shin pointed out the harmful health effects of economic sanctions and the political use of food aid led by the US government.2 The role of the South Korean government in addition to that of the US government would be also crucial because, along with China, South Korea has been a major trade partner of North Korea as well as a major donor country to North Korea for food aid during the most recent decade.10–12 A clear example of the use of political and economic measures for political leverage was the sudden shutdown of the Kaesong Industrial Complex, the most important economic zone for inter-Korean economic cooperation. At the height of the tension in 2013, and as I was writing the editorial,1 the factories of 123 South Korean companies in North Korea were shuttered; about 54 000 North Korean employees were laid off and about 200 000 family members were affected. The relationship of job loss with increased morbidity and mortality risks has been well documented.13,14 However, the international and South Korean media covered the political and economic aspects of the closure but gave little attention to the potential impacts of job loss on living standards and health of North Korean employees and their families. The difference in life expectancy between the two Koreas was less than 3 years in 1993 but increased to about 12 years in 1998.15 The fact that the 12-year difference in life expectancy has remained ever since15 suggests that a constant humanitarian crisis, which could be called a slow-motion holocaust, is going on in North Korea. Concerns have been raised regarding food aid to North Korea, including inequitable distribution of food, lack of a monitoring system, and other uses of the food assistance (e.g., reselling in private markets and funding nuclear programmes).12 However, considering the expected short-term health impacts of food shortages and their long-term health and social consequences, the imperative to provide food aid to North Korea may well outweigh such concerns.