International Journal of Epidemiology, 2014, Vol. 43, No. 4
org/stellent/groups/public/documents/ena/wfp243024.pdf
(30
October 2013, date last accessed).
9. Schwekendiek D. Determinants of well-being in North Korea:
Evidence from the post-famine period. Econ Hum Biol
2008;6:446–54.
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10. Abramowitz M. U.S. Hypocrisy Starves North Korea. National
Interest, 2012. http://nationalinterest.org/commentary/us-hyp
ocrisy-starves-north-korea-6435 (30 October 2013, date last
accessed).
International Journal of Epidemiology, 2014, 1341–1342
Author’s Response to: Two Koreas
doi: 10.1093/ije/dyu016
Advance
Access
Publication
Date:
10 February 2014
and public health: ‘First, do no harm’
From Young-Ho Khang
Institute of Health Policy and Management, Seoul National University, College of Medicine, 103 Daehak-no Jongno-gu,
Seoul, 110-799 Korea. E-mail: [email protected]
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
C The Author 2014; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association
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health and social consequences, the imperative to provide
food aid to North Korea may well outweigh such
concerns.
References
1. Khang YH. Two Koreas, war and health. Int J Epidemiol
2013;42:925–29.
2. Shin S. Two Koreas and public health: ‘First, do no harm’. Int J
Epidemiol doi:10.1093.ije/dyu014
3. Goodkind D, West L, Johnson P. A Reassessment of Mortality
in North Korea, 1993–2008. Available at: http://paa2011.
princeton.edu/papers/111030 (17 December 2013, date last
accessed).
4. Spoorenberg T, Schwekendiek D. Demographic changes in
North Korea, 1993-2008. Popul Devt Rev 2012;38:133–58.
5. Schwekendiek D. From pre- to post-famine: Trends in underweight among North Korean children, 1987-2012. North Korean Rev 2013;9:59–68.
6. Schwekendiek D. Determinants of well-Being in North Korea:
Evidence from the post-famine period. Econ Hum Biol
2008;6:446–54.
7. Stein Z, Susser M, Saenger G, Marolla F. Famine and Human
Development. The Dutch Hunger Winter of 1944-1945. New
York: Oxford University Press, 1975.
Ad hominen or ad rem? Good
autocorrelation or bad?
International Journal of Epidemiology, 2014, Vol. 43, No. 4
8. Neugebauer R, Hoek HW, Susser E. Prenatal exposure to wartime famine and development of antisocial personality disorder
in early adulthood. JAMA 1999;282:455–62.
9. Schwekendiek D, Pak S. Recent growth of children in the two
Koreas: a meta-analysis. Econ Hum Biol 2009;7:109–12.
10. Jeong H-G, Bang H. An Analysis of North Korea’s
Principal Trade Relations. Paris: IFRI Center for Asian Studies,
2010.
11. Haggard S, Noland M. Sanctioning North Korea: The political
economy of denuclearization and proliferation. Asian Surv
2010;50:539–68.
12. Manyin ME, Nikitin MB. Foreign Assistance to North Korea.
Congressional Research Service, 2009. http://fpc.state.gov/
documents/organization/130260.pdf (17 December 2013, date
last accessed).
13. Kasl S, Jones B. The impact of job loss and retirement on health.
In: Berkman L, Kawachi I (eds). Social Epidemiology. New
York: Oxford University Press, 2000.
14. Browning M, Heinesen E. Effect of job loss due to plant closure
on mortality and hospitalization. J Health Econ 2012;
31:599–616.
15. Korean Statistical Information Service. North Korean Statistics.
http://kosis.kr/statisticsList/statisticsList_03List.jsp?vwcd¼MT_
BUKHAN&parmTabId¼M_03_02 (5 December 2013, date last
accessed).
International Journal of Epidemiology, 2014, 1342–1343
doi: 10.1093/ije/dyu097
Advance Access Publication Date: 26 April 2014
Ralph Catalano
School of Public Health, University of California Berkeley, 322 Warren Hall, Berkeley, CA 94720, USA.
E-mail: [email protected]
Rodriguez et al.1 have invoked two defences against my
commentary2 on their recent report of an association between Republican presidencies and infant mortality.3 First,
they label my criticism as ‘ad hominen’. This powerful juju
implies that I could find no fault in their argument and
could discredit it only by discrediting them. I think most
readers of IJE will find my criticisms entirely ad rem. I,
moreover, had no need to resort to ad hominem criticism
since the paper in question presented much to criticize.
Second, the authors claim that ARIMA modelling identifies and controls for higher-order autocorrelation that
arises from public policy and does not, therefore, provide a
fair test of their hypothesis. To put it simply, the authors
imply that autocorrelation in a time series divides into
good and bad—bad includes that which makes the estimation of confidence intervals difficult whereas good includes
that which induces association between the dependent and
independent variables. They further claim that when they
applied a (2,1,2) ARIMA model to the infant mortality
data they still found an association. I believe I have a creditable record as a time-series analyst. As such, I can find no
identification strategy by which a (2,1,2) ARIMA model
would fit the US infant mortality series.
As Bayes described long ago, whether association arising from shared autocorrelation makes us more confident
about a causal argument depends on our ‘priors’. Those
who believe, as a matter of political faith, that Republican
presidents do bad things to the governed will find shared
autocorrelation compelling evidence of causation. Those
who want Republicans to govern will dismiss the association by citing, explicitly or intuitively, the Granger/Wiener causality theorem. The rest of us will go on wondering
how to understand ‘political epidemiology’. How does it
differ from political economy, policy analysis or
C The Author 2014; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association
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