When North Korea declared its first major Covid outbreak in May, leader Kim Jong-un described it as the greatest “turmoil” to befall the country in 70 years, while public health officials predicted an apocalyptic disaster with a potentially massive death toll.
Some two months on the isolated country – which has barely vaccinated its malnourished population, and which lacks the medicines to treat them – appears to have defied the pandemic odds.
Pyongyang has lifted its lockdown, allowing citizens to return to work, and the regime claims to have tamed the spread of the virus. As of Friday, it had recorded a total of 4.74 million “fever” patients, plus an improbably low death toll of just 73.
Few believe the figures. The authoritarian state strictly controls access and information, and has a vested interest in touting its success in overcoming a virus that has wreaked havoc in the West. The country also lacks testing facilities, instead marking cases by the presence of a “fever” – a less common symptom of the omicron variant.
“The point here is that they said there were 4.5m cases of fever. I wonder if the number of actual confirmed cases was higher, like double that,” Kee Park, director of the Korea Health Policy Project at Harvard Medical School, told the Telegraph.
But he added: “Everybody, including myself, predicted a very high-risk population in North Korea – malnutrition, immunologically naïve, and compared with other countries of similar income levels and health systems, predicted a case fatality rate of around 1-1.5 per cent.”
This could have meant a death toll upwards of 45,000 people. “That didn’t materialise – at least we don’t think so,” said Dr Park. “The North Korean authorities are also surprised. I think they were braced for the worst, and it wasn’t as bad as they expected,” said the neurosurgeon, who has visited the country on several occasions.
How and why remains a mystery, but theories abound. Some say the death rate appears low because people have been dying silently in their homes without seeking medical treatment, as many did during a brutal famine in the 1990s.
Others say the timing of the Covid outbreak may have spared the country the Covid catastrophe anticipated even by the regime itself, as the spread was dominated by the less virulent omicron variant. The country was also able to enforce tight, swift lockdowns, while the population of 26m has resilience after decades of enduring disease and harsh conditions.
Survival of the fittest
According to Dr Park, North Korea appears to have followed a pattern similar to that of Malawi, Tanzania and Madagascar, where Covid-19 swept through the low vaccinated populations without a calamitous outcome for public health.
That hypothesis leads to a somewhat grim conclusion. In some countries, including North Korea, the population may already have been “selected out to be the survivors. So, the ones who were weak to begin with never survived,” said Dr Park.
This contrasts to wealthier countries, he said, where chronic patients are propped up by a robust medical system. The more vulnerable are the “first ones to go” when a pandemic strikes.
Meanwhile Kim Sin-gon, professor at Korea University’s College of Medicine in Seoul, suggested low-income countries may weather Covid-19 better because of pre-existing immunity from other disease outbreaks.
“Countries that had a lot of exposure to viruses develop a level of cross-protective immunity, and North Korea could be one of those countries,” he told The Wall Street Journal.
But even if North Korea survives the pandemic relatively unscathed, the prospect of a bigger threat of starvation, worsened by sweeping punitive sanctions as well as pandemic isolation, is looming large, warn experts.
“We don’t have anything other than sporadic reports out of North Korea, but they are pretty steadily reporting starvation and it’s logically impossible that there couldn’t have been starvation given that we know what is going in and we know what people need,” said Prof Hazel Smith, of the Centre for Korea Studies at the School of Oriental and African Studies.
North Korea’s food insecurity problems long pre-date the pandemic. According to a 2019 assessment by the World Food Programme, 11m people (out of a population of 26m) were undernourished and in need of humanitarian assistance.
Prof Smith attributes a “catastrophic” fall in agricultural production to the imposition of comprehensive UN sanctions against North Korea in 2017 to curb its nuclear weapons programme.
‘People will just go home and die’
She warned that sanctions, natural disasters, pandemic border closures and trading bans had combined to create the same level of food insecurity as seen in the famine years of the 1990s: “Disastrous food harvests four years in a row, and a lack of ability for the population to buy food from abroad.”
Household and government food stocks were now likely running dry, she said, adding: “The scale of the food deficit is absolutely enormous.”
An estimated 240,000 to 3.5m people died of starvation or hunger-related illnesses during the North Korean famine of 1994 to 1998, also known as the “Arduous March”.
Prof Smith, who lived in North Korea working for UN humanitarian organisations in the two years following the famine, believes up to half a million died over a period of about four years, and likely did so at home.
“It’s easily possible that that situation could replicate itself. So you don’t have mass starvation out in the streets but you have people dying earlier, in childbirth, from illnesses they wouldn’t have died from if they weren’t hungry,” she said.
It’s a phenomenon that may also be occurring during the Covid outbreak, she suggested.
“People will just go home and die, just like the last time,” she said, casting doubt on the official Covid-19 fatality rate.
The dire situation leaves Pyongyang with a choice of whether to continue with its draconian “zero Covid” policy or cautiously learn to live with the virus and reopen the borders for trade, boosting the economy and tackling food insecurity.
Dr Park believes there are signs the outbreak has prompted the regime to adopt the second approach, and begin slowly lowering restrictions.
“If they are smart then they are shifting from zero Covid… to now saying we have millions of people potentially infected and it isn’t overwhelming our health system, let’s just tap on the brakes, let’s not go for zero Covid anymore because this is a way to vaccinate the whole population,” he said.
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