In 2018, for example, the Global Fund to Fight AIDS, Tuberculosis and Malaria mysteriously stopped funding a lifesaving tuberculosis program in North Korea. Some experts have suggested that Japan and the United States, the largest donors to the Global Fund, may have played a role in the decision.

Another example is the more well-known “unintended” humanitarian consequences of the multilateral sanctions regime against North Korea. These sanctions have markedly reduced the flow of aid to North Korea as well as crippled the country’s ability to care for its people. The North Korean government is also not blameless. The government has in the past expelled humanitarian organizations with little warning and frequently refuses aid, including food and vaccines.

Nevertheless, a new framework, based on humanitarian principles and applied through a comprehensive, multiyear, multi-donor, and politically protected approach could lead to sustained health cooperation and improved lives for ordinary North Korean people. Furthermore, if all sides behave in good faith on health cooperation then trust can be built, which can open up possibilities for engagement in other areas.

The United States and North Korea have not had any substantive dialogue since October 2019, when the last official contact occurred at a working-level meeting in Stockholm. During the series of summits between the leaders of the United States and North Korea in 2018 and 2019, a mutual belief that good faith dialogue could lead to breakthroughs kept the process moving forward. However, the talks collapsed with the failure to reach an agreement at the February 2019 Hanoi summit. Despite the U.S. government’s stated willingness to meet with North Korea without any preconditions, anywhere and anytime, Pyongyang has not responded.

Principles of Humanitarian Assistance

The four guiding principles for humanitarian assistance are humanity, neutrality, impartiality and independence. The United Nations General Assembly adopted and endorsed the first three principles in 1991 and then in 2003 added independence (from political, economic and military objectives) as the fourth core principle essential to humanitarian action. Yet, both the United States and North Korea have often ignored these principles. The questions are: Can the two sides agree to abide by these principles, at least in part? Most importantly, can the relevant health and humanitarian organizations be allowed to operate autonomously in North Korea, independent from political, economic and military objectives on both sides?

It would be naïve to believe that the two countries would adhere to all these principles perfectly. These core principles are aspirational, and in the real world actual implementation varies. The important part, however, is to try to develop a framework for future humanitarian engagement between North Korea and the international community. For such a negotiation, narrowing the focus to health cooperation first makes sense for several reasons.

Why Start with Health Cooperation?

A 2022 U.N. report stated that undernourishment among North Korea’s population of 25 million reached 41.6 percent during 2019 to 2021 compared to 33.8 percent during 2004 to 2006. The country’s susceptibility to natural disasters, such as typhoons, flooding and droughts, also exacerbates the related problems of food access, potable water, sanitation and diseases.

At the same time, as a socialist state, North Korea under its constitution guarantees free healthcare for all. While the country’s provision of medical care faces many challenges due to the lack of resources and international sanctions, the public health system is surprisingly effective. For example, prior to the COVID-19 pandemic, the country achieved 97%–98% coverage for essential childhood vaccines. The country also managed to emerge from the pandemic with reportedly few COVID deaths. These figures are debatable and unconfirmed, but North Korea appears confident, having started to carefully and selectively reopen its borders. What is not debatable is the importance of health in the government’s priorities.

North Korea is also importing record amounts of health-related goods, such as medicines and medical equipment, at least from China, since the movement of cargo resumed last year. According to Chinese customs data, North Korea purchased approximately $45 million in pharmaceuticals alone in 2022 and is likely to surpass that amount in 2023. This is a dramatic increase compared to under $5 million each in 2016 and 2017 and slightly more than 2018 and 2019. Furthermore, the Korea Health Policy Project, which I lead at Harvard Medical School, estimates that North Korea imported at least 150 invasive ventilators in 2022 — enough to equip Pyongyang and all the provincial hospitals. North Korea is increasing its spending on health for its people in an unprecedented way.

Lastly, North Korea is an active participant in the U.N. system. With North Korea being voted in as a member of the Executive Board of the World Health Organization (WHO) this past May, its involvement in global health governance is expected to increase. Compared to the U.N. Security Council, the WHO, governed by its member states and devoid of any veto power, may be a better platform for developing an agreed framework for health cooperation between North Korea and WHO member states.

A Comprehensive, Multi-Donor, Multiyear Approach Is Key to Sustainability

Past health-related projects with North Korea have oftentimes been hindered by political factors. The largest international health cooperation project in North Korea — the South Korea-funded WHO/United Nations Children’s Fund (UNICEF) project (approximately $65 million) — ran from 2006 to 2015 and helped improve maternal and child health. Despite the positive outcomes, the project suffered from frequent interruptions in funding flow and subsequent programming — ostensibly due to South Korean politics. Recently, North Korea cancelled a $5 million South Korea-funded WHO follow-up project to improve pediatric surgical care, indicating its unwillingness to accept any assistance from South Korea. Looking forward, a multi-donor, pooled fund, set aside in a trust fund managed by a neutral committee, may help protect the funding flows from being subject to political pressure and ensure uninterrupted programming.

Ideally, the new framework should be comprehensive, multi-donor and multiyear. Comprehensive means the aim should be to strengthen the entire health system — training the workforce, improving infrastructure, information management and service delivery, and building governance capacity. A pandemic preparedness and response plan should be integrated into the overall scope of cooperation. Developmental assistance, such as technology transfer for vaccine development and manufacturing, should also be on the table. Similar to previous large-scale health cooperation projects, North Korea will likely choose its implementation partners from among its allies and neutral partners. For example, countries like Vietnam, China, India and Thailand have provided training and personnel in the past.

It would not be advisable to seek funding on a yearly basis like the U.N.’s annual appeal for funding for urgent humanitarian needs in North Korea. Instead, a multiyear funding commitment, perhaps five years, is needed to maintain continuity in programming, promote efficiencies and build a robust and resilient corridor for health cooperation.

There has been a convergence toward a systems approach by many of the largest health funders like the Global Fund and the Global Alliance for Vaccines and Immunizations (GAVI) along with the North Korean Ministry of Public Health. In theory, these system-wide interventions would be resistant to political influences, especially if implemented strategically with goals and targets over several years. While large-scale, multiyear, multi-stakeholder projects are obviously difficult to fund and implement, once established and with guardrails in place, such projects are harder to stop than short-term, specific interventions. 

To be clear, trust building will only occur when the United States and North Korea change behavior that has in the past prevented principled health cooperation. The United States can greenlight the creation of a trust fund that is protected from political pressures and concurrently establish an unfettered health and humanitarian corridor within the existing sanctions regime. Such actions can build a favorable environment for a multiyear comprehensive health cooperation package through existing international organizations like the WHO. Given the current relations, the United States and its allies are unlikely to be active implementation partners. Nevertheless, there are a number of countries and nongovernmental organizations that have worked with North Korea in the past and should be able to support full implementation.

As a physician and global public health practitioner, I should be clear about motives. Humanity dictates we should be concerned for one another and alleviate suffering and save lives when possible. We should also come alongside those who are trying to help themselves in a spirit of solidarity. The effort to develop a new framework for health cooperation with North Korea should stem from the desire to improve the lives of millions of North Korean people rather than a desire to open up potential opportunities for diplomacy. However, if the process of working together toward the common goal of improving the health of the North Korean people leads to increased trust and reduced tensions between two adversaries, then everyone benefits.

Dr. Kee B. Park is a lecturer on global health and social medicine at Harvard Medical School. As a neurosurgeon, he has travelled to North Korea over 20 times to work alongside North Korean physicians.