US and North Korea agree on at least one thing: Healthcare

US and North Korea agree on at least one thing: Healthcare
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On Sunday, President TrumpDonald John TrumpGOP divided over impeachment trial strategy Official testifies that Bolton had 'one-on-one meeting' with Trump over Ukraine aid Louisiana governor wins re-election MORE reinvigorated the U.S.-North Korea diplomatic process by convincing Kim Jong UnKim Jong UnOvernight Defense: Ex-Ukraine ambassador offers dramatic day of testimony | Talks of 'crisis' at State Department | Trump tweets criticism of envoy during hearing | Dems warn against 'witness intimidation' | Trump defends his 'freedom of speech' Biden responds to North Korea: 'I wear their insults as a badge of honor' Erdoğan should receive the wrath of the US, not its embrace MORE to meet him at the Demilitarized Zone and stepping onto North Korean soil, a first for a sitting U.S. president.

The diplomatic process has come to a standstill since the failed talks at Hanoi in February. One outcome of this weekend’s encounter was the welcome resumption of working-level negotiations. The photos of the two smiling leaders masked the pervasive lack of confidence between the two nations, which threaten to derail the future talks.

What can the U.S. do to build trust while maintaining tactical pressure during denuclearization talks? One opportunity for the U.S. to transform the relationship with the North Korea — as per the Singapore Statement — is to support North Korea in their effort to strengthen surgical care. Interestingly, the U.S. and the North Korea have already agreed on this important matter — in theory.

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During the 68th World Health Assembly in 2015, there was a resolution introduced called “Strengthening emergency and essential surgical care and anesthesia as a component of Universal Health Coverage”. JON Sang Chol from the Democratic People’s Republic of Korea Mission spoke in favor of the resolution. Few minutes later, Stephanie Martone of the U.S. Mission said that the U.S. is pleased to co-sponsor the resolution; the resolution passed unanimously. 

The U.S. and North Korea may disagree in many ways, but here, they both agree on the importance of universal access to emergency and essential surgical care. The resolution asks member states to “prioritize a core set of emergency and essential surgery and anesthesia services at… first-referral hospital level.” Further, the director-general of the WHO is mandated to “support national, regional, and global efforts to … strengthen surgical care and anesthesia.”

Did the North Korea Ministry of public health follow through with the mandates of the resolution? From a policy standpoint, they did. The 2016-2020 Medium Term Strategic Plan for the Development of the Health Sector for DPR Korea includes the following strategic item: “introduction of the WHO Emergency Essential Surgical Package at the first referral level.”

By integrating the surgical care strengthening to their district health systems, the DPRK plans to reduce the number of disabling conditions like cataracts, improve maternal and children’s health, treat cervical and breast cancer; and provide timely treatment of obstetric emergencies. Well, it’s 2019, four years into the five-year plan. What progress have they made? 

A nationwide surgical care-strengthening project in a developing country typically requires large investments for improving the infrastructure, procuring of surgical equipment, and training of surgical workforce. For Zambia (population 17 million) the estimated cost is $400 million.

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For Tanzania (population 57 million) the expected cost is $600 million. Financing and operationalizing these national plans are not simple or easy for any country. For North Korea, these challenges are compounded by the most complex sanctions regime in history, donor reluctance, and lack of access to development banks. So despite their intent to implement a massive surgical capacity building project, the prospects of such a project coming together are dim — or are they?

Since January of this year, the U.S. has relaxed its criteria for exempting humanitarian assistance for North Korea. Two months ago, the State Department granted me a special validation passport for travel to North Korea to perform humanitarian surgeries, in contrast to last year when a similar request was denied. Most recently, a UNICEF request for exemption for North Korea bound medical equipment was approved in a neck snapping two-weeks.  

There are several reasons why the U.S. should choose to allow or even support North Korea’s efforts to strengthen surgical care for its people.

First, cooperation between the U.S. and North Korea on improving the health of North Korean people would transform the relationship between the two countries and supports the spirit of the Singapore Statement.

Second, the project is aimed at strengthening surgical services at the first-line facilities. So the beneficiaries are the ordinary citizens of North Korea, including mothers and children.

Third, a large-scale, multi-year, multi-stakeholder health project can help smooth out the diplomatic process through bumpy times. 

Fourth, no sanctions would need to be rolled back as humanitarian aid, including health projects, are already exempted from the sanctions.

To some, humanitarian aid to North Korea is worrisome as they believe such assistance would allow the regime to spend money elsewhere. In the case of surgical expansion, if North Korea agrees to co-finance 20 percent of the project as they do now for vaccinations with Gavi, they would need to find $100 million from their current budget to pay for it. (Assumes $500 million as the total cost) In such a scenario, they would have less money to spend elsewhere.

Another concern is the risk of diversion. Although there were reports of diversion in the 1990’s, presently, there is no evidence of systematic large-scale diversion of aid. Also, even though the UN agencies in-country have been able to gradually improve monitoring capabilities, the current funding gaps could lead to degradation of monitoring capacity.

However, a massive health project led by the UN agencies would give significant leverage for these agencies to bolster the monitoring capacity. Further, medical equipment is easier to monitor since verifying that a piece of equipment is where it is supposed to be is much simpler than monitoring food aid.

As a matter of principle, humanitarian aid, including health assistance, should be based on need only and never be used for achieving political objectives. Yet, there are practical political implications that can result from humanitarian assistance and these should not be ignored. The U.S. is in a position to help by widening the current humanitarian channels and maybe even seeking to be a major stakeholder of the project. What better way is there to build confidence between two historical adversaries than to work together to help the sick and the injured?

Kee B. Park, M.D. MPH, has visited North Korea 20 times as the director of the North Korea Programs at the Korean American Medical Association. He is a lecturer on Global Health and Social Medicine with the Program in Global Surgery and Social Change at Harvard Medical School and serves on the Expert Advisory Panel on Surgical Care and Anesthesia at the World Health Organization. Follow him on Twitter @keepark.