Nutrition in the DPRK - a field view

By Marie-France Bourgeois

Marie-France Bourgeois spent four months at the end of 1997 monitoring and co-ordinating ECHO funded programmes in DPRK. In that time, she travelled extensively through six of the nine provinces, surveying 70 health institutions and 25 social service facilities. She returned for a one month evaluation visit in April 1998.

This article, provides an 'experience based' sequel to Field Exchange's analysis of the DPRK crisis (see issue 3). It casts doubt on claims of widespread malnutrition, focuses on the appalling state of care available to chronically malnourished children, and highlights the considerable operational difficulties in running nutritional programmes in DPRK.

Introduction

Between 1995 and 1997, ECHO provided 1.29 Million ECU in aid to the DPRK. Following an evaluation mission in early 1997, which reported "serious food shortages, and the collapse of the public health system". ECHO dramatically increased its funding to DPRK (9 Million ECU). Assistance was primarily targeted at nutritional rehabilitation and therapeutic assistance for severely malnourished children and distribution of medicines and medical equipment to hospitals. In 1998, ECHO provided 8 Million ECU to fund nutritional rehabilitation programmes, distribution of medicines, water and sanitation programmes and the rehabilitation of centres for the elderly.

ECHO's partners

The international community had one sole partner at government level: the Flood Damage Rehabilitation Committee (FDRC), which comes under the umbrella of the Ministry of Foreign Affairs and is responsible for co-ordinating humanitarian donations and expatriate activities in country. At the outset, ECHO funded both UNICEF and MSF programs. UNICEF programmes focused on the training of medical staff country wide in identifying and treating malnutrition with high energy milk. Meanwhile, MSF's programmes (made up of three teams from France, Belgium and Netherlands) reinforced UNICEF's initial training. They also set up Therapeutic Feeding Centres (TFCs) at both the provincial and city hospital levels within the three provinces they were allowed to cover, (Kangwon, North Hwanghae and South Pyongyan). In 1997, ECHO also funded other NGOs, such as Children Aid Direct (supplementary feeding programme) and CESVI (distribution of essential drugs). IFRC also received funding to establish programmes for the victims of the August typhoon.

Levels of Malnutrition

Even after a continuous year of NGO presence, no plausible anthropometric survey details have emerged from DPRK. It was impossible to identify levels of malnutrition from the 'official' but unsubstantiated Ministry of Health statistic, which was vaguely quoted as 15%.
A gross estimate from personal observation would be that child wasting affected no more than 10% of the 3,000 children I saw in nurseries and kindergartens (this is only an approximate figure, for I was never allowed to use a MUAC tape nor did I have access to proper weighing and measuring equipment). Overall, it would appear that the main problem North Korean children were facing was stunted growth, due to long-term macro and micro dietary deficiencies, coupled with chronic diarrhoeal disease (associated with a poor water supply) as well as lack of pharmaceutical supplies. During visits to 70 provincial, county and paediatric hospitals, I never saw more than 15 children being treated for malnutrition, most of which was in the form of mild PEM. I saw very few marasmic children. The worst concentration of severe malnutrition I witnessed over the five months, was six marasmic infants under the care of the Hamhung Children's centre, in South Hamgyong province. Older children's needs, while recognised, were neglected as interventions were focussed on addressing the complexities of service delivery for younger age groups.

Children's Centres

Through ECHO funding, UNICEF implemented a nutritional programme at the 9 Children's Centre which housed children aged from a few weeks to five years old who have no immediate family to care for them. Activities included;

• medical staff training in identification and management of severe malnutrition,
• distribution of HEM and multivitamins (amounts were provided based on information provided by the FDRC on the
• number of attendants per institution)
• Ad hoc distribution of CSB, pulses and maize in partnership with WFP.

At the Hamhung centre where I came across the six marasmic infants, I noted a fully stocked warehouse containing a three month supply of CSB, DSM, HEM, multivitamins, maize, sugar and oil! The nutritional rehabilitation and management procedure for these infants, when explained by the staff, was difficult to follow. I was told they were using DSM as a substitute for breast milk, yet informed at the same time, that wet nurses (whom I never met) came several times a day. Clearly this practice of offering non fortified DSM on its own, or combined with infrequent breastfeeding was a sure path to acute malnutrition! My suggestion of using appropriately diluted HEM instead of DSM was met with vigorous opposition from staff, arguing that UNICEF might somehow not approve. Six months later, MDM (Medecins du Monde), who had been given responsibility for 'nutritional rehabilitation of the province', highlighted the problem of infant malnutrition at the Children's Centre. Apparently, medical staff had not changed their approach to infant feeding. Another very disturbing feature at Hamhung centre was what I called the 'left over chamber' where about 20 children ranging in age from one month to five years were kept. Their overall health, nutritional and hygienic condition was appalling, with many suffering from skin conditions. I had a strong impression that these children had been left 'unattended' for long periods. Some, having fallen over onto their sides, seemed to lack enough energy to sit themselves up. Staff informed me that the children had 'just' arrived two or three days ago, and that they would be taken care of later on that day.

Elsewhere in these centres, where the nurse/child ratio was approximately 1:8, children seemed to be suffering mainly from chronic malnutrition. With it came a general air of apathy and a palpable silence. There was little evidence of efforts by staff to stimulate play or cognitive development in these children.

Operational Constraints

NGOs based in the DPRK faced enormous obstacles in their collaborative efforts to provide humanitarian assistance to those most in need. Examples of these are set out below:

Government level.

• All humanitarian donations, programmes and expatriate activities were co-ordinated, 'processed' and monitored by the Flood Damage Rehabilitation Committee (FDRC). It was felt that the constant presence of a government 'delegation' when working with local counterparts, inhibited exchange of information and hindered us in developing effective working relationships.
• The FDRC restricted access to certain areas.
• Despite a socialist philosophy, inequities in provision of equipment and distribution of supplies to certain children's centres were evident. As the Korean population is categorised into three main groups on a scale of 'loyalty' to 'disloyalty' to the party, I wondered whether children from less 'loyal' groups received marginalised care ?
• General infrastructure has collapsed due to general structural problems resulting from economic collapse. Therefore severe fuel shortages and power cuts were commonplace; houses had no lighting at night, and no medical institution had access to an emergency generator. Access to clean water was a constant problem. Some hospitals however had their own wells; those without were supplied with water filters by MSF.

Health service / Children's centre level.

• The medical staff have received little training in identifying and treating malnutrition. The medical training and equipment is obsolete (dating most likely from the 1950s and not upgraded since then) One recently opened TFC run by MDM-France has increasing attendance rates which demonstrates Koreans willingness to attend clinics when there is proper care and access to medicines.
• Chronic shortage of essential drugs was a problem. Pharmaceutical drugs have not been produced in DPRK since 1995 (the few supplies of penicillin and aspirin I came across were already out of date). It is common practice for doctors to prescribe pharmaceutical drugs for a two day period only, after which they prescribe traditional 'koryo' herbal medicines. According to medical sources, koryo medicine is used for 85% of all prescriptions due to lack of essential drugs in the country.
• Inappropriate storage and re-allocation of supplies disrupted service efficacy. I frequently noted that although weight for height charts, MUAC tapes and Salter scales had been received by a centre, they had never been used and were neatly stored in a locked room! Similarly, the fact that child health and nutritional status rarely seemed to improve in centres in spite of evident supplies of HEM, vitamins, essential drugs, ORS, etc, suggested the use of these items was being restricted in order to make savings. This suspicion was confirmed by the discovery of several tons of HEM and medicines stockpiled in warehouses. In the provinces, there was a tendency to re-allocate essential drugs and HEM in an ad hoc manner ignoring the targeting strategy previously agreed with international agencies. I discovered this when I came across day clinics issuing HEM that had been earmarked for hospital use only. Furthermore, none of the doctors issuing the milk were clear about its function. On top of that, the familiarity with HEM at local level led to it being perceived as 'normal dried powder drinking milk'; so that I was treated to a warm 'cuppa' of HEM on some of my outreach visits !
• While health data collection and drug consumption monitoring systems have been put in place by NGOs in several locations, the political commitment to implement these systems remains questionable.

Conclusion

Whilst no one has been able to statistically demonstrate the true extent of malnutrition in DPRK, it is obvious that the country faces serious problems of access to food and medicines. However the strategy to target nutritional rehabilitation at the severely malnourished in institutions, in the absence of freedom to determine where most nutritional problems exist, must limit the impact of these programmes. More worrying is the risk that material resources, e.g. HEM intended for nutritional rehabilitation is and will continue to be, misused in the absence of adequate training and monitoring. At grassroots level, I feel that a substantial proportion of health staff who received updated training have shown a keen interest in acquiring additional knowledge, demonstrating the potential for capacity building within the country. However, the DPRK system of government casts a shadow over how much freedom health staff can exercise when choosing treatment regimes.
In April 1998, at the donors' round table in Geneva, the DPRK authorities made it clear to those present that its main aid requirements were for fertilisers and seeds. Meanwhile, according to the North Korean authorities, the on-going health programmes are no longer required. Indeed the DPRK have asked specifically for help in producing their own medicines. As of August 1998, several medical NGOs did not have their Memorandum of Understanding renewed by the FDRC. Some have already left the country and others will follow shortly. One can only be left to wonder seriously about the future of DPRK health service provision. As far as I remember, I was told over and over again in the countryside that our aid was most welcomed, but central government appears to have decided otherwise, in the name of Juche, the North Korean philosophy of self reliance.