The Gathering Health Storm Inside North Korea

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H. ANDREW SCHWARTZ: North Korea is the impossible state. It’s a place that’s stumped leaders and policymakers for more than three decades.

MR. : (From recording.) Seventy percent of North Koreans are food insecure, and half of them are malnourished.

MR. SCHWARTZ: It has a complex history. And it has become the United States’ top national security priority.

MS. : (From recording.) They were doing relatively well until the collapse of the Soviet Union. They lost the client-state status. And then that was exacerbated by the droughts, by the floods, by the por agricultural production.

MR. SCHWARTZ: Each week on this show we’ll talk with the people who know the most about North Korea: CSIS’s Victor Cha, Mike Green, and Sue Mi Terry.

In this episode of The Impossible State, we welcome Steve Morrison. Steve is the director of the CSIS Global Health Policy Center. Steve recently produced a documentary about the health crisis in North Korea. So along with my colleague Victor Cha we sat down with Steve to discuss the documentary, “The Gathering Health Storm Inside North Korea.”

Gentlemen, there’s a gathering health storm inside North Korea. And, Steve and Victor, we just produced a film to that effect. Tell us what the gathering storm is, Steve.

J. STEPHEN MORRISON: Well, we pulled people together in the spring. This is part of our Commission on Health Security. We pulled together members of that commission, and Victor and other experts on North Korea, to sort of look at the idea of – for the impoverished rural majority within North Korea – this is a population that’s been oppressed and maligned forever – are there deep health insecurities and vulnerabilities in that population? And the answer is yes. And the more we dug in and looked at it, the data’s not great, but we know enough, and we began talking to folks who are operational in North Korea.

MR. SCHWARTZ: Well, how do we know the data? Where do we get it from?

MR. MORRISON: Well, let’s take MDR TB, right? I mean, the multidrug –

MR. SCHWARTZ: Multidrug, yeah.

MR. MORRISON: Multidrug-resistant tuberculosis, which for the rural population and the rural majority in North Korea it’s way off the charts.

MR. SCHWARTZ: There’s 16,000 afflicted with this.

MR. MORRISON: Sixteen thousand cases estimated, only 2,000 in any treatment form; highly lethal and highly contagious. How do we know that? We know that from – principally from talking to some of the Evangelical Christian operators who have been working there for years: the Eugene Bell Foundation, which has done – has exported 800 cases, sputum cases, and then analyzed those a few years ago. We know that from talking to the World Health Organization office; from talking to the folks in UNICEF who work on these matters; from talking to Heidi Linton, who is with Christian Friends of Korea. So they are folks that are very skilled, savvy, professional, who have good working relations with the health ministry there, who are doing survey work across a spectrum of these issues.

So the data is not across-the-board terrible. There are some – and we put that data in the film around MDR TB, around stunting, around fecal contamination of drinking water. All of that sort of data is contained in this most recent UNICEF survey that came out in July, first time in nine years that you had a national survey on children’s and adult health in North Korea.

MR. SCHWARTZ: But it’s not all bad news?

MR. MORRISON: Well, the thesis that we make here is that the overall situation is pretty terrible. If you look at the decrepitude of the health infrastructure in the country, you look at malnutrition and stunting, you look at MDR tuberculosis and more broadly drug-susceptible tuberculosis, you look at low agricultural productivity, vulnerability to famine and drought, and misrule, this is a population that doesn’t have a whole lot of margin for error. And the basic proposition – and this is something where Victor and Sue Mi Terry were very helpful – is that this is a form – this is a very brittle – it’s a tinderbox. It’s a situation that with a few mistakes around the margins could really be quite destabilizing.

MR. SCHWARTZ: Yeah. Victor, will you tell us about that?

VICTOR CHA: Yeah. I mean, I think generally when we look at North Korea everybody is focused on nuclear weapons, the ballistic missiles, the threats, you know, firing artillery, submarines, things of that nature.

MR. SCHWARTZ: And now we’re focused with a potential second summit.

MR. CHA: Yeah, a potential second summit. But, you know, I think that the title of the film is appropriate, the gathering storm inside of North Korea, because this has been a problem that has been there for a long time. The only reason it hasn’t spread more widely is because the people aren’t able to move. I mean, if these people were able to move – I mean, most of them are in the neglected provinces in North Korea where there’s very little transportation. If they were able to move, this would be something that would be spreading across borders, particularly the Chinese border. But –

MR. SCHWARTZ: We’re talking pandemic.

MR. CHA: Pandemic, yeah. But the – and the main point is that, you know, they are really, I think, one pandemic away from, you know, major regime dislocation. And I say that because – I don’t say that in an ideological sense. I say it in an empirical sense, in that you just have to look at the way the government has responded every time there has been a pandemic in Asia, whether it’s avian flu, the Ebola outbreak even in West Africa, I mean, SARS, the Middle East respiratory syndrome in South Korea. You look at the way the government completely shuts everything down, it shows you that they are paranoid that if this gets into their country they have no ability to deal with it.

So, just to give you one example, I remember when the MERS crisis struck South Korea, right, because there was – South Korea was the largest outside the Middle East, right? And –

MR. SCHWARTZ: Remind us what MERS is.

MR. MORRISON: It’s an upper respiratory, highly contagious outbreak. And the actual animal carrier is thought to be camels. And it’s primarily based in Saudi Arabia and the Emirates but has had export.

MR. SCHWARTZ: But it was spreading all over, yeah.

MR. MORRISON: And it got into the heath system in Seoul, which was not equipped for the prevention and control of the – of the infectious disease. And so it became this very interesting test case, and it set off quite a panic because it’s highly lethal.

MR. CHA: Yeah. And this was South Korea. This is an advanced industrialized society that had – that had to deal with it. So you can imagine North Korea.

But anyway, what North Korea did was they completely shut down. I met with one of the EU diplomats who is based in North Korea, and he was coming through Washington, and he said that essentially there was like if you leave the country, when you come back in you have to go through a two-week quarantine. And then –


MR. CHA: Yeah. And in his case, he was – he was going back to North Korea for 10 days, and then he was going to Japan for a day, so he had to – (laughs) – he had to go into quarantine, out for two days, and then back in and start all over again.


MR. CHA: But that’s how serious they take these things in the sense that the government, they don’t – they don’t think they’re able to handle something like this were it to happen.

MR. SCHWARTZ: And they view this as a – as a direct threat to their stability of the regime.

MR. CHA: I would think so. I mean, the way that they handle, sort of completely shutting everything down, is a sign to me that they see it as very threatening to the overall internal order in the country.

MR. SCHWARTZ: So, unchecked – what could happen if the health crisis is unchecked there?

MR. CHA: Well, I mean, you know, it’s an interesting question because North Korea is a place where the only organized institution of social order is the military, right, and the military is very rarely challenged. And so the question is, if something happens where people resist because they’re not getting what they need – in this case, treatment for their children or others – how are they going to respond? The closest we’ve come to seeing something like this is when the government has undertaken anti-market activities where we have heard anecdotes of social resistance in the markets, largely by women who are running the markets, against local soldiers and things of that nature. But if this were something that was, you know, much more widespread, where families and their kids were sick and the government was not providing them any help – because they couldn’t, they can’t, they don’t know how – it’s not clear either how the government would respond – would they declare martial law and crack down on everybody? Or would the people just overrun – you know, overrun the capital? It’s not clear.

MR. MORRISON: Or would they flee to the neighboring states?

MR. CHA: Or would they flee? Or would they flee to China?

MR. MORRISON: If the – if the opportunity presented itself. And then would they be exporting MDR TB, exporting other diseases if there was a pandemic outbreak? So they don’t have the – they don’t even have the systems of surveillance and control. They don’t have the basic systems of global health security to give you confidence that they actually know when their outbreaks are happening and then they have the ability to track, monitor, intervene, and control those outbreaks. And they’ve got this multitude of different calamities in the health sector that make it highly fragile. And so people could potentially take matters into their own hands.

Back to one of your earlier questions around, you know, what’s being done on this, there have been expanded efforts by the U.N. and by some of the international NGOs, particularly the American Evangelical NGOs who play a critically important role, at trying to build up in recent years – build up their engagement. And so WHO, UNICEF, World Food Programme have all been able to do things. Gavi Alliance has been able to get the immunization rates up to 96, 97 percent from the low 60s in the last eight or 10 years by working with the ministry.

MR. SCHWARTZ: Immunization for what? Which –

MR. MORRISON: Basic childhood – I mean, most vaccines are for under five, right?

MR. SCHWARTZ: Yeah. Yeah.

MR. MORRISON: So the battery of essential vaccines that – vaccinations that you want.

MR. SCHWARTZ: Is now available?

MR. MORRISON: Yes, and the coverage rates have expanded. There’s been dramatic progress on immunizations, childhood immunizations, because the Gavi Alliance has quietly gone in there and taken some risks and been able to work cooperatively. They’re not facing any problems of diversion. They don’t have monitoring problems, which is something we can talk more about.

And WHO and World Food Programme and UNICEF have been able to expand the work that they do on malaria control and on tuberculosis control. The Global Fund, until June of this year, had a – has spent about $100 million on tuberculosis control and malaria, but they ended that program – and we can come to that, too – in June because of political pressures and because of quite justifiable concerns around prospects of diversion, and they didn’t want to be running afoul of sanctions and be accused of not being very fastidious about all of that.

MR. SCHWARTZ: So on the one hand there’s a – there’s a good news story: people are being immunized, organizations – international NGOs are being let in to do some work.

MR. MORRISON: Recently.

MR. SCHWARTZ: Recently. On the other hand, I’m hearing a very fragile environment. It sounds like a very dry forest that is susceptible to one match that could just inflame the entire region.

MR. MORRISON: Right. And then you add on top of that we’ve had some gains recently by – we’ve just described, but they’re still way back, right, in the back of the pack in terms of where they are, and highly fragile. And then you add in the accelerated effort to get nuclear weapons and missile systems, and then that triggers the imposition of comprehensive sanctions and the drift towards maximum pressure and the like.

Well, that’s – even though there are carveouts, humanitarian exemptions for health and humanitarian work, under the sanctions and under our own legislation in the U.S., the net result has been that people – the escalation of the confrontation with the Koreans has scared people away, right? It’s the donor – the appeal that the U.N. put forward earlier this year, $111 million, it’s only subscribed at about 20 percent of the level. The money is drying up going into the international – the major international operators.

The sanctions committees are very hard to get through, so that the NGOs are spending vast amounts of resources trying to get their stuff through the committees, and their programs have dropped by three-quarters. And then you have the pressures to not give – you know, with the administration you’re trying to put maximum pressure on Kim Jong-un. They’ve begun denying visas to some of the NGOs to operate. UNICEF is finding that in the sanctions committee they’re getting turned down on some of their shipments.

Cash banking – banking transfer mechanisms for the NGOs and the international agencies have fallen apart, so they’re having to move cash in and out, physically carrying cash. That’s dangerous. That’s very difficult.

So it’s – there’s a bit of a crisis right now for the U.N. agencies that do work in this area and for the NGOs. And the question is, do they get crushed and shut down? Or do the talks advance and, in fact, there’s an opening? Because when you look at the situation, if the talks fail, there’s no good option there for the – for the health and humanitarian folks if things continue along the – along the trajectory they’re on right now. If talks advance in some way, the – naturally, the parties – the U.S. and the North Koreans and others – are going to migrate towards the non-sanctioned areas, where they can do more – do good things without having to automatically lift the sanctions.

MR. SCHWARTZ: So, Victor, why is this crisis in North Korea so seldom discussed?

MR. CHA: The health crisis?


MR. CHA: I think it’s just because everybody’s focused on the nuclear weapons. That’s what the sanctions are focused on. I mean, there has been a paradigm shift in the sense that for a long period of time, even though we had nuclear crisis, nuclear sanctions with North Korea, the humanitarian stuff was kind of left alone for the most part. It operated on a separate track. So if negotiation were going well, the humanitarian stuff just went along as it normally would. Even if negotiations were going badly, the humanitarian people were allowed to do their work very quietly, low level. It really started to change in the sense that the humanitarian piece became part of the negotiations during the Obama administration, where a decision was made to essentially take what was the remainder of rice and humanitarian shipments from a Bush-era deal that was – a Bush-era deal that was eventually suspended. There were still remainders there to be given to the North Koreans, rice, and they made that – the Obama administration pulled that into a broader discussion on trying to get the nuclear negotiations restarted. And the Trump administration has now in part – because we’ve gone to maximum pressure has sort of pulled everything in, including the humanitarian stuff into this.

So when Steve – you know, Steve’s right in the sense that now everything depends on these nuclear negotiations. And if these things don’t go well, then the humanitarian stuff has no hope whatsoever. So that does make it a lot more difficult.

The United States has always been of the view that sanctions are meant to target the elite in North Korea, not the people. But since we moved to maximum pressure and since the U.N. actually moved to maximum pressure, sanctioning regular commerce and other sorts of things, now these sanctions are affecting everybody. And then the humanitarian – they’re not humanitarian sanctions, but sanctions have been pulled in – are affecting the most vulnerable populations in the country.

MR. SCHWARTZ: Yeah. So, for instance, 70 percent of North Koreans are food insecure, and the youth of North Korea are – their growth is stunted. So that’s a direct result of what you’re talking about.

MR. CHA: Yeah. I mean, I would say that that’s a direct result of mismanagement of resources by the regime. This is one of the few industrialized societies in modern history to have suffered a famine because of pure economic mismanagement.

I mean, this is a country that has lots of resources, lots of mineral resources. If you look at the Korean Peninsula, the northern part are where all the resources are; the southern part is the breadbasket, or the ricebasket. So they have a – they have a lot of resources, but they just mismanaged them and created a famine.

However, the fact that humanitarian assistance isn’t allowed in, of course, is affecting, you know, vulnerable populations that have nothing to do with the nuclear program whatsoever. And we can talk about this. The main argument against a lot of this assistance is concerns about diversion, access, and monitoring. Maybe Steve wants to talk about that. But you know, the groups that we have talked to in the course of this project and then at the event this week, you know, they argue that these are not real issues.

But still, in a sanctions committee, right, when something comes up to a sanctions committee, you know, their number-one concern is, one, does this technically – does this piece of equipment technically violate the sanctions; and then, can it be diverted, right, so that – like, it doesn’t go to the kids –

MR. SCHWARTZ: To dual use.

MR. CHA: – it ends up going to the military or even to the military’s family, or something like that.

MR. SCHWARTZ: So where does this leave us? I mean, and how hard is it for humanitarian organizations to get in there now?

MR. MORRISON: Well, it’s getting increasingly very difficult, and the anxiety levels at the U.N. and among the NGOs are way up. Way up.

MR. SCHWARTZ: Why is it getting more difficult? If President Trump is negotiating directly with Kim Jong-un and Pompeo is traveling there frequently, why is it getting harder for NGOs and humanitarian assistance to get in there?

MR. MORRISON: Because the maximum pressure approach, which is the approach to try and get the denuclearization agenda to move forward, is sweeping in the humanitarian and health assistance. So it’s – while it is formally exempted, the reality is it’s getting sanctioned and people are scared. They don’t want to be seen as – in any light as operating in defiance or breach of the sanctions, even if they’re operating – if you follow me.

MR. SCHWARTZ: Yeah, sure.

MR. MORRISON: So why did The Global Fund shut down a vitally important program? Because they couldn’t say to their own board: We are categorically completely confident that all of these resources are going to the intended beneficiaries, and none are being diverted to the elites or the militaries. And they – their major funders were also, I think, pushing them on this too. You know, I think the U.S. and the Japanese were – wanted to make sure that the fund wasn’t on the wrong –

MR. CHA: In violation of U.S. law right? (Laughs.)

MR. MORRISON: Yeah. They were very concerned about this. So those pressures are really, really intense right now. And that’s why you’re hearing these voices of distress and of alarm that are coming out of the World Food Programme and UNICEF and WHO and out of the evangelicals. And I’d add in there the Samaritan’s Purse, which has a long record of responding particularly to flooding and other natural disasters. There has been a recent case of flooding this year, which is an annual, cyclical problem. But also we’ve heard – we heard yesterday in the public sessions, we heard in the private session from – you know, from Christian Friends of Korea, from Heidi Linton –

MR. SCHWARTZ: This is the – we had a luncheon roundtable with senior officials from the United States government, from NGOs, from all over the place discussing these issues before – right.

MR. MORRISON: Yes. Yeah. In a very civil, and open, constructive way. It was – Heidi was speaking very dramatically around this is the situation we face, and this is what we’re struggling to do. And I think to put this in context, you know, Christian Friends of Korea is one instance. It’s a small NGO. It’s been around for 23 years. It’s had a continuous program of access. And it’s been able to prove over and over again that the dollars invested in them – mostly privately raised from private individuals and church communities and the like – that those moneys are well-spent, and they’re – and they’re going towards targeted health interventions with direct benefit to the poorest and most vulnerable populations. That’s who they serve.

And they’ve built up a national institute for monitoring the tuberculosis, which did not exist, which is an – you know, an essential element of being able to get a national response, is being able to track and surveil what is going on. And that is imperiled as well.

MR. CHA: I mean, for listeners, one way to think about it is we are now basically in, let’s say, what, the 22nd month of a maximum pressure sanctions campaign on North Korea. And this – you know, the good news for sanctioners, is this is a comprehensive approach. We haven’t had this before with regard to North Korea. The bad news is that things like humanitarian assistance becomes collateral damage in an approach like this, in the sense that even if places like The Global Fund are not technically in violation of the sanctions, there is an echo effect because now many things that were considered track two humanitarian come under increased scrutiny, right? I mean, you know, you need a Treasury license to do things that you didn’t have to do before. So people naturally get worried. They don’t want to be in violation of U.S. law because they have equities beyond North Korea, right, in all the other places they work. So then they make a choice, like, do we really want to stay here and risk, you know, our reputation and possibly be in violation of U.S. law, or not? And many of them choose not to be.

The second thing is that – what we haven’t talked about is sort of China’s role in all this. If there were some sort of crisis where all of a sudden North Koreans started coming across the border, the most likely place they’d go is China, right? There’s the – Jilin province is not within walking distance, but certainly within distance of the border, you know, over – it’s the largest ethnic Korean overseas population in the world. If they start going to Jilin province, nobody will be able to find them, right? If people with tuberculosis started going in there. So how are the Chinese going to respond? Are they going to shut the border? Are they going to start shooting them as they come – you know, this has follow-on effects that rapidly become a major security issue, not just – not just a health –

MR. MORRISON: And you see the refugee camps they built inside – just inside the border in the last phase, where they thought there as going to be armed confrontation and they were expecting out migration. And so the strategy was to have the capacity to contain them at the border.

MR. CHA: Yeah.

MR. SCHWARTZ: And clearly, China has to be thinking about this in terms of its own national security.

MR. CHA: Yeah. I think they are. I mean, they’ve always wanted North Korea as a buffer state. But I think there are two sort of concerns they have, aside from the traditional ones about a U.S.-DPRK conflict. One of them is a nuclear accident, because their nuclear test site is close to their border. And then other is this – is that this – and the nuclear test site is something, again, that’s talked about a lot, right? We’ve talked about it a lot. You see it in track one as well as in track two. But the one that’s not talked about is the public health – potential public health crisis.

MR. SCHWARTZ: How hard is it for us to get a full picture of the health situation in North Korea?

MR. MORRISON: Well, what you’re pointing to is one of the things that needs to happen right now, which is we should intensify the pressure on the regime and DPRK to allow much greater access for international operators to verify – monitor and verify what they do.

MR. SCHWARTZ: And this is what we’re recommending to the United States government.

MR. MORRISON: Yes. We should make that part of our current strategy, take that issue away so that you relieve – you lower the anxiety that Victor was just talking about among the international operators – the NGOs and the U.N. agencies and others, and restore the confidence of the donors that they can put their money in. Because right now, you’ve got an appeal. You have a mechanism out there to put money into to get resources in. But it’s only 20 percent funded because folks have walked away because they just don’t think it’s a good bet. Well, you need to turn around that psychology.

And one step would be put it back at the door of the government of North Korea to say, OK, let’s – and Governor Beasley, who’s the head of WFP, the World Food Programme, was there in July. That was a topic front and center. He went and visited four provinces, two very remote ones. They hadn’t had access before. Mark Lowcock, who’s the head of the U.N. OCHA, the body. He was just there. Same message. You’ve got to do this. And they just released 10 million in emergency funds to start to try and at least keep some of the UNICEF programs, particularly in tuberculosis, alive for another few months. Get some buffer stocks. Get some – you know, some – a little bit of margin so that the 120,000 people who were on treatment for tuberculosis under the World – under The Global Fund grant, don’t get cut off in this – in this next phase. So that’s one thing.

But the other thing is, you know, we have to prepare for very divergent outcomes, right? On the one hand, we have to prepare for the possibility that the talks fail. And if that’s true, how do you delink humanitarian and health programs from the broader set of sanctions so that you can get that space revalidated, so that those exemptions are revalidated and reactivated? That’s one scenario. Another scenario is we get some progress. The maximum pressure works. There’s some traction. And people are motivated to say, well, let’s do more to build confidence and show good faith and accomplish something.

And the first place they’re going to look is health and humanitarian. So I think there we should be trying to get planning – strategic planning underway with the South Koreans, the Chinese, ourselves, the EU, the World Bank and others, so that when the doors do open we know what it is we want to do. And we’ve got priorities in our own heads. And we’re not just there listening to what the DPRK says, because the DPRK is going to come in with a fairly narrow set of priorities, versus what should be a broader strategy. And the last thing that we’re arguing is that there’s a lot we don’t know.

And if we – if we could be pressing the regime to allow in teams of researchers to do some applied research right now, get that exempted, get folks going in and doing some collaborative research that fills in a lot of the gaps of what we don’t know today, that we’d be in a much better position if the – if the positive scenario materializes and if the negative materializes. We’re still in a much better position to understand what the true needs are.

We’ve got almost 80 NIH-funded research grants underway in South Korea. We have almost 300 in China. So we have a series of elaborate partnerships in that region on applied research that could be leveraged and activated. And we’ve got a variety of universities that have some active partnerships that have existed in North Korea. There’s any number of ways that this could be – this could be turned to our advantage.

MR. CHA: I mean, if we put this in the context of the broader negotiation – so if we ever get to the point where North Korea gets sanctions lifting, they’re going to want sanctions lifting on other things, right?

MR. SCHWARTZ: More than this?

MR. CHA: Things different – they’re going to want cash money. That’s what they’re going to want. They’re going to want something like that. And of course, that’s –

MR. SCHWARTZ: As our colleague Sue Mi Terry says, they never do anything for free.

MR. CHA: Right. They never do anything for free. So they’re going to certainly want something along those lines. You know, basically money that they can get, that they can do to, like, restart the Kaesong Industrial Complex, where they have total control over everything and it doesn’t go to the people. So if you think about what Steve is talking about, there are ways of trying to say, look, all right, we’re ready for sanctions lifting. But we’re going to lift sanctions on something else. And in this case, health and humanitarian assistance.

Now, ideally that should not be part of it, but it’s been collateral damage. So we have to live with it now. So that should be one of the first things that we can offer in terms of sanctions lifting, not only to help the people but from the broader negotiation. It’s a good indicator of whether they’re actually serious about reform, if they actually want to join the community of nations or not. I mean, we were talking about this while we were in Korea last week.

Similar sort of concept, which is that, you know, North Korea – one of the things that should happen in sanctions lifting is the IMF or someone should just go in and say: We have all these information requirements. Like, if we’re going to start projects, we need to know all this information. So are you willing to provide that information? Same thing on the health side. If we’re really going to help you, we need to see if you’re willing to give us this information.

These are, in the broader negotiation, a great way to be able to tell whether they are actually serious about reform outside of the back and forth on the nuclear issue, because historically that’s the only thing we focused on, is the nuclear issue. And we try to understand whether North Korea is serious by the small steps they take on the nuclear issue, after two failed nuclear agreements. So this would be a new way of approaching it and saying let’s try to get a sense of whether they’re serious by pointing to other things, right, and seeing if they’re willing to accept assistance, provide information on these other things.

MR. MORRISON: The whole point of pushing the regime to allow agencies to have much better access to prove that they are capable of monitoring. I mean, if WHO can take a lead role in that, UNICEF can take a lead role in that, WFP can play a lead role in that, and be able to demonstrate that progress is possible. If they’re pushing, and if the major powers – the U.S. and others – are behind them saying: This needs to happen. And you’re not going to funding for that appeal unless we get much greater confidence that we’re not getting diversions.

In terms of how much diversion actually happens, as I mentioned earlier, the Gavi Alliance has been able to raise the immunization rates to almost 100 percent in the last 10 years, from a low of 60 percent.

MR. SCHWARTZ: So we know that’s being diverted.

MR. MORRISON: It’s a big win. There’s been no allegations of any diversions there. What we’ve heard from UNICEF is they feel much more confident in the last eight to 10 years in their ability to move and get permission to move into various places. They still are not at will mobile. They still – they can – they have – they have permission to go to every county in the country, but they have to get forward permission. They can’t just spot verifications. Well, that’s something that perhaps should be pushed on to get greater access of that kind.

Some things that – like in the health sphere, some of the machinery that’s used in high-tech testing, gene expert machines and the like, they’re complicated and difficult. How much dual use do they have? They have a lot of metal in them, et cetera. I’m skeptical that these can be diverted into – into security uses. I do agree that there’s always pressure to take highly valued commodities and direct them to the elites or to the military, to the more empowered. And that’s going to be a concern.

MR. CHA: Whenever you’re talking about North Korea, diversion is always an issue. But at the same time, when I was last in government there was a negotiation that the United States government did with North Korea where they were negotiating on behalf of the U.S. government, the World Food Programme, and, what is it, five American NGOs, to negotiate access and monitoring requirements. And they were successful. So there is a template out there for now to negotiate these sorts of things with North Korea.

MR. MORRISON: And this was in ’07 and ’08.

MR. CHA: Yeah, this was ’07-’08.

MR. MORRISON: And they had a negotiated protocol that went on for pages and pages and pages on all the specific measures. And it worked, right?

MR. CHA: It worked, yeah.

MR. MORRISON: And then the program was suspended when they moved toward nuclear testing in ’09, right? They were – they were asked to leave. But we heard this yesterday from Jon Brause from World Food Programme, who was part of those negotiations.

MR. CHA: Yeah. In ’07-’08, it wasn’t that the United States government pulled the assistance because of the nuclear tests. The North Koreans asked for these groups to leave. And so it was – from a U.S. policy perspective, the humanitarian part was not a part of the broader nuclear negotiation. But later on, it got pulled in and became collateral damage for the – to the negotiations.

MR. SCHWARTZ: So, Victor, you’re not in the prediction business – especially since your Giants are, like 1-in-6 right now. So I know that you don’t want to – but what do you predict happens here with this situation with regard to –

MR. CHA: With the Giants?

MR. SCHWARTZ: No, no, not with the Giants. Not with the Giants. With regard to the gathering health storm?

MR. CHA: I would say it’s the low probability, high consequence event that we don’t really think about. We’re always worried about leaking nuclear materials, a crisis that escalates out of control, a conventional crisis that escalates out of control. But where we have a complete blind spot for is this particular issue and this particular scenario. And, you know, I’m hoping that, like, the work that Steve is doing, the UNICEF report that you’re talking about, will have the same sort of impact that the 2012 U.N. – sorry – 2014 U.N. Commission of Inquiry Report had on the human rights issue, is to sort of put this on the radar screen and create a groundswell of interest focus, policy focus, that this is a real issue that needs to be addressed in North Korea.

MR. MORRISON: In the near term, if we’re in a stalled waiting period on an indefinite basis under that scenario, I think the health conditions will deteriorate. You know, we’re already beginning to see the dismantling and the decline of programs. It’s already – we heard about this yesterday from UNICEF and the World Food Programme and from the NGOs that their programs have been cut by half, three-quarters. The beneficiaries are going to – their health status will deteriorate. So you’re going to see a decline of the health status of the rural impoverished majority in the country in this next period. And that will be a quiet crisis. That’s not going to be a loud crisis, I don’t think. Or one that’s all that visible to us. So that is one reality.

Another thing – another question is, how do we get these issues in front of other parties that really matter here? How do we get this in front of the Japanese, the South Koreans, the Chinese, the EU? How do we do that? And that’s something that was raised yesterday, and I think that’s a challenge, because this isn’t just an American issue. This isn’t just an issue of American policy. These are U.N. sanctions, right? This is a U.N. sanctions committee. And it’s one where there are many parties to this which have a stake in understanding the magnitude of the problem. They have an immediate stake within the region.

And they need to be, I think, brought on board about this. And I think that’s one area where we can be a little bit more aggressive and clever in how we market the work that we’ve done on the written, and the film, and podcasts like this. I’ve talked to the Japanese. And Victor had some ideas. I’m not sure that the South Koreans, or the Chinese, or the Japanese are necessarily making these issues top line, but we’ve got to at least get them into the consciousness of folks and into the conversation. I think we’ve been successful at demonstrating that the policymakers in this administration are fully aware today of the situation. They’ve reached out. They’ve gotten smart on what this all means.

And I think that’s progress, of a kind. It hasn’t changed the fundamentals that we talked about in terms of the maximum pressure now sweeping the health and humanitarian in. But there’s a sensitivity to this and an awareness that if circumstanced changed they’re going to need to be quick off the dime in trying to put programs together that begin to redress this process of deterioration that we’re seeing.

MR. SCHWARTZ: The documentary is “The Gathering Health Storm Inside North Korea.” You can view it at And we’ll put the exact URL inside the podcast notice for this episode. Thank you, gentlemen, for joining us.

MR. MORRISON: Thanks, Andrew.

MR. CHA: Thanks, Andrew.

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If you want to dive deeper into the issues surrounding North Korea, check out Beyond Parallel. That’s our micro website that’s dedicated to bringing a better understanding of the Korean Peninsula. You can find it at

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This is The Impossible State.