International Journal of Epidemiology, 2014, 1340–1341
doi: 10.1093/ije/dyu014
Advance Access Publication Date: 10 February 2014
Letters to the Editor
Letters to the Editor
Two Koreas and public health: ‘First, do no harm’
From Sanghyuk S Shin
Program in Global Health, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Ave.,
CHS 12-105, MC: 739516, Los Angeles, CA 90095, USA. E-mail: [email protected]
In Khang’s insightful article regarding public health in
North and South Korea, the author suggested that ‘militant’ reaction against North Korea could harm public
health efforts.1 Likewise, ‘militant’ international policies
exist that are clearly harmful to public health in North
Korea. For example, despite the ongoing public health crisis in North Korea, the country remains under economic
sanctions from the USA, Japan and the United Nations.2
Epidemiological studies have consistently shown that economic sanctions lead to dramatic increases in morbidity
and mortality.3–5 Economic sanctions are particularly
harmful to the most vulnerable segments of the targeted
country’s population.5 Indeed, economic sanctions have
been called a ‘tool of warfare’ because of their devastating
impact on health and human rights.6 Therefore, the continuation of economic sanctions in North Korea is unacceptable from a public health standpoint.
Another policy, albeit an unofficial one, that has
harmed public health in North Korea is the use of humanitarian aid for political leverage. For example, the Bush administration withdrew food aid from North Korea in 2008
citing deficiencies in aid monitoring.7 This was done despite significant improvements in the quality of aid monitoring in North Korea through the years and assurance from
on-the-ground aid personnel that the vast majority of the
food aid was reaching the intended beneficiaries.7,8 Furthermore, nutritional surveys have shown that food aid has
significantly improved children’s nutritional status in
North Korea.9 Although the official US policy is that humanitarian aid is to be provided based solely on need, the
withdrawal of food aid in 2008 to gain political concessions from North Korea is consistent with a longstanding
pattern of using aid for political aims by US
administrations.7 Unfortunately, this unofficial policy continues to harm vulnerable North Koreans today under the
Obama administration.10
Khang asserted that the public health community could
contribute to preventing war and improving health in the
two Koreas.1 We should also insist that our governments
practice the fundamental medical principle: ‘First, do no
harm’.
References
1. Khang Y-H. Two Koreas, war and health. Int J Epidemiol
2013;42:925–29.
2. Wertz D, Vaez A. Sanctions and Nonproliferation in North
Korea and Iran: A Comparative analysis. Federation of
American Scientists, 2012. http://www.ncnk.org/resources/
publications/Comparative_Iran_North_Korea_Sanctions.pdf
(30 October 2013, date last accessed).
3. Ali MM, Shah IH. Sanctions and childhood mortality in Iraq.
Lancet 2000;355:1851–57.
4. Garfield R, Santana S. The impact of the economic crisis and the
US embargo on health in Cuba. Am J Public Health 1997;
87:15–20.
5. Gibbons E, Garfield R. The impact of economic sanctions on
health and human rights in Haiti, 1991-1994. Am J Public
Health 1999;89:1499–504.
6. Gordon J. Economic sanctions, just war doctrine, and the fearful
spectacle of the civilian dead. Cross Curr 49:387–400.
7. Manyin ME, Nikitin MB. Foreign Assistance to North Korea.
Congressional Research Service, 2009. http://fpc.state.gov/docu
ments/organization/130260.pdf (30 October 2013, date last
accessed).
8. Food and Agricultural Organization, World Food Programme.
Democratic People’s Republic of Korea – FAO/WFP Crop and
Food Security Assessment Mission. 2011. http://documents.wfp.
C The Author 2014; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association
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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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