Why Foreign Aid Matters in North Korea’s COVID-19 Crisis

North Korea’s leader Kim Jong Un is pulling out all the stops to combat a massive COVID-19 outbreak that could force the reclusive state to open up to external assistance.

After Pyongyang went public about the outbreak on May 12—the first time during the pandemic that North Korea admitted to coronavirus within its borders—Kim began attending emergency meetings almost every day. He put a national lockdown in place, sent military personnel to distribute medicine and publicly criticized officials for not keeping drug stock available.

None of this is standard behavior for Kim, whose propaganda machinery goes to great lengths to portray “Dear Leader” as a steady hand on the tiller. However, he is right to be concerned. Since confirmation of the first COVID-19 case just last week, nearly two million people have succumbed to what the state-run Korean Central News Agency refers to as “fever.” On Thursday alone, the country reported 262,270 new cases. A “high incidence” of the fever has been reported in the capital, where it has claimed 62 lives.

TIME has been told by experts that the 25 million-strong state will have difficulty confirming if these are COVID-19 cases. This could lead to insufficient testing capabilities, making it difficult to determine the spread of the disease. With poor health infrastructure and lack of vaccines exacerbating the health crisis, North Korea may see a ballooning of casualties—unless it asks for help.

Is Kim capable of doing that? Central to his governance is his grandfather Kim Jong Il’s JucheA political philosophy that encourages self-reliance and independence. Pyongyang rejected previous requests from humanitarian organizations and countries for vaccines, insisting instead on closing the borders to prevent infection.

Although COVID-19 figures from the country are unreliable, North Korea’s admission of such high numbers may be taken as a sign of a policy rethink and being receptive to help, says Lim Sojin, associate professor of North Korea studies at the U.K.’s University of Central Lancashire. According to her, Pyongyang will be able to book its first quota from the WHO-led COVAX vaccination sharing program. This reduced the jabs allowed for North Korea’s 8.11 million to 1.54 million in the last year. It also allows Pyongyang the opportunity to rebook the shipments. “It’s a really nice way to save their face,” Lim says.

North Korea’s potentially ‘destabilizing’ COVID outbreak

North Korea has been plagued by economic problems like food insecurity for a long time. The state chooses to invest large amounts of GDP on military and nuclear programs over civilian resources. The pandemic has worsened the economy even further; South Korea’s central bank estimated a 23-year record contraction in 2020. Kim has promised to solve the “food, clothing and housing problem for the people” but has instead focused on missile launches—inviting more sanctions on the nuclear state.

Undernourishment is a result of chronic food insecurity. More than 40% of the population do not have their daily nutrition needs met. According to a U.N. 2019 report, nearly 10 million North Koreans don’t have safe drinking water access and 16% lack basic sanitation facilities. This puts them at high risk for severe diseases.

In a report submitted to the U.N. in 2021, North Korea itself reported a “lack of capacity of health personnel, low technical foundation of pharmaceutical and medical appliance plants and shortage of essential medicines.” Pharmacies also reportedly lack medical supplies and storage facilities. The lack of heat and poor electricity supply also affect hospitals.

Continue reading: COVID-19 Finally Slipped Through North Korea’s Borders. Here’s What to Know About the ‘Explosive’ Outbreak

Given these, a massive outbreak in North Korea would be “dangerous” and “potentially destabilizing,” according to J. Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies in Washington. High fatalities are predicted, as well as an increase in mortality rates of up to 1% and perhaps half-a-million or more cases of severe illnesses.

North Koreans have a median age of 35 which could help to reduce the chance of dying. But the country “has a very fragmented and weak health infrastructure which will be easily overwhelmed and they do not have medical stockpiles that are of any use in this situation,” Morrison says.

Kim, who has not yet made public the inability to control the outbreak by local health authorities, is now calling on his military personnel to fight the epidemic.

Residents were previously advised to use painkillers, antibiotics and antivirals rather than taking them. Traditional medicine like japonica and burdock root was also supported by the state media. With the COVID-19 situation quickly changing, North Korea now has two choices: let Omicron run riot and suffer the consequences or offer assistance.

“It’s very late in the day—there are no good options,” Morrison says. “It’s too late to prevent a very bad outbreak. But if you reopened rapidly, you could begin to lower the suffering levels and begin to build back for the future.”

The problem with foreign assistance

The possibility exists that external help may be allowed in. According to unnamed sources, Pyongyang sent three Air Koryo aircraft into Shenyang in China on May 16, and they returned with supplies the next day. Kim has praised China’s handling of the epidemic, even though the giant neighbor is also currently struggling to contain outbreaks.

Baek Jieun, a research fellow with the Korea Project at Belfer Center at Harvard Kennedy School, says these signal the situation inside the state is “dire” enough for a policy change.

Kim “really went on this message for the past two years that they can do all this by themselves,” Baek tells TIME. “The fact that they very explicitly went to another country—albeit it’s China, a friendly country—undercuts his message that they’re going to solve the COVID-19 problem by themselves, which is actually kind of a hit to his legitimacy.”

South Korea offered to supply vaccines, personnel and equipment. However, it says that the North has yet not responded. The U.S. has said it won’t deliver vaccines to North Korea directly, but is fully supportive of the global COVAX initiative.

Continue reading: As the City’s COVID-19 Lockdown Tightens Again, Shanghai Residents Have Been Pushed to Breaking Point

Should the U.S. decide to offer help, Baek says he hopes Kim would accept it, even though he isn’t likely to. “I hope Kim Jong Un does not reject the donation, because the citizens of North Korea would really benefit.”

Lim from the University of Central Lancashire said that North Korea doesn’t know how to use the accountability and paperwork of humanitarian organizations giving aid. But this shouldn’t deter countries from offering aid, she says.

The way that the assistance is provided matters equally. Lim says foreign statements and sanctions related to North Korea’s nuclearization at a time of COVID-19 turmoil may cause Pyongyang to question the aid given to them.

“We really need more engagement and take a more customized approach to North Korea rather than denuclearization-first-and-lifting-sanctions-after,” she says. “This kind of rhetoric does not work anymore.”

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