OVERVIEW OF THE SITUATION
Amid continuing geopolitical dynamics the situation for millions of people in the DPR Korea (DPRK) remains grim. The country’s most vulnerable people struggle with food insecurity and undernutrition and lack of access to basic services. As a result, around 10.9 million people remain in need of humanitarian assistance to cover their food, nutrition, health and water, sanitation and hygiene needs.
Chronic food insecurity
Chronic food insecurity and malnutrition is widespread in DPR Korea (DPRK), with profound humanitarian impacts for the most vulnerable people in the country. An estimated 11 million people, or 43.4 per cent of the population, are undernourished. Agriculture annually falls short of meeting the needs by approximately one million tonnes, due to shortages of arable land, lack of access to modern agricultural equipment and fertilizers, and recurrent natural disasters. In July-August of 2018, there was a severe heat wave in the provinces considered to be the ‘food basket’ of the country, with temperatures up to 11 degrees higher than average. The chronic humanitarian situation was then further aggravated by Typhoon Soulik in late August, which brought heavy rains to South Hamgyong and Kangwon provinces, as well as flash floods on 29 and 30 August 2018 in North and South Hwanghae provinces.
Recurrent natural disasters, such as droughts and floods, significantly impact on the productivity of cooperative farms, which are responsible for national food production, and thus on overall food security. Productive assets need to be rehabilitated as a result of natural disasters and enhanced to ensure access to food and other essential services for people in need. This includes rehabilitation of irrigation networks and stabilization of flood-damaged riverbanks and embankments. For humanitarian partners there is a critical role in reinforcing household and community resilience, as well is maintaining access to the most vulnerable populations, particularly following a disaster. Emergency preparedness measures directly mitigate the impact of disasters on farms and vulnerable communities that are critical to preventing a decline in food security and an increase in malnutrition rates.
Food insecurity is compounded by poor dietary diversity, which is a major concern for most of the population. There are also persistent gaps in nutritional status between rural and urban populations that need to be reduced. The Global Hunger Index (GHI) has classified the level of hunger in DPRK as ‘serious’ and ‘bordering on alarming,’ with DPRK ranked 109 out of 119 qualifying countries2 . The deteriorating food security situation is reflected in a score of 34 in 2018 - the highest score since 2000 - compared to a score of 28.2 in 2017. DPRK remains heavily reliant on domestic food production for its food security.
Due to reduced crop production, as well as the impact of the floods and heatwave, food insecurity will increase in 2019, particularly among the most vulnerable. As there is strong link between food insecurity and malnutrition, any negative impact on food access and availability has widespread and long-lasting impacts and risks jeopardising gains that have been made in malnutrition rates.
Undernutrition is countrywide
Food insecurity and the nutritional status of people in DPRK are strongly interrelated. Many people do not consume an adequately diverse diet, reinforcing the cycle of undernutrition. In particular, young children and pregnant and lactating women suffer from chronic malnutrition because their diets lack vitamins, minerals, proteins and fats. According to the 2017 Multiple Indicator Cluster Survey (MICS), conducted by the Central Bureau of Statistics with support from UNICEF, one in five children in DPRK are stunted (chronically malnourished). These children will struggle to lead a normal life, facing impaired physical and cognitive development that cannot be reversed later in life. In addition to the effects of stunting being irreversible, these are also often passed on from one generation to another, creating a self-perpetuating cycle - malnourished women are more likely to have malnourished children.
In resource-poor settings, food scarcity leads to diets that are low in nutrient density, with negative impacts for children’s growth. According to the MICS, one-third of children aged 6-23 months do not receive the minimum acceptable diet, the combination of both the minimum diversity of foods and minimum number of feeds. Significant variations exist between provinces and between rural and urban households. For example, in North Hwanghae Province, two-thirds do not receive the minimum diet diversity, compared with just one-fifth of children in Pyongyang Province.
Although the national rate of stunting has dropped significantly from 28 per cent in 2012 to 19 per cent in 2017, significant regional differences exist, varying from 10 per cent in Pyongyang Province to 32 per cent in Ryanggang Province. Furthermore, girls have a higher stunting rate (19.9 per cent) compared to boys (18.4 per cent). There are also significant variations by age group, with the percentage of stunted children increasing with age after one year, after complementary feeding should be introduced. The percentage of stunted children is highest in the age group 48-59 months, at 26 per cent.
In addition, an estimated three per cent of under-five children (approximately 140,000) suffer from wasting or acute malnutrition. Children affected by wasting have a higher risk of mortality. The main underlying causes of wasting are poor household food security, inadequate feeding and care practices, as well as poor access to health, water, hygiene and sanitation services. Wasting also plays a part in the vicious cycle of infection: undernutrition increases susceptibility to infection, and infection then leads to greater weight loss due to appetite loss and poor intestinal absorption. Moreover, there is an established relationship between poor nutrition and increased vulnerability to some diseases, including tuberculosis (TB).
Access to basic health services
In DPRK, communicable and non-communicable diseases remain major health concerns. Around nine million people are estimated to have limited access to quality health services. While health facilities exist throughout the country, they often do not have the essential medical equipment or life-saving medicines to provide quality health services. There is limited quality comprehensive health services, including for sexual and reproductive health, child health, disability and aged care, as well as for communicable and non-communicable diseases.
There is also limited professional competencies of health care providers to deliver at all levels of the health system; a situation that is exacerbated in primary health care level and more remote and rural areas. Furthermore, many health facilities struggle to maintain consistent water and electricity supplies putting patients at increased risk of infection and death.
In recent years there have been significant improvements in rates of infant and child mortality, a clear indication that humanitarian aid is making an impact in the lives of the most vulnerable. The current infant mortality rate is estimated at 12 per 1,000 live births, compared to 16 per 1,000 live births 10 years ago and under-five mortality is estimated at 15 per 1,000 live births, compared to 20 per 1,000 live births 10 years ago. High immunization coverage, at more than 95 per cent, has contributed significantly to these achievements, but is highly donor dependent. Despite this, young children continue to die from common and preventable childhood illnesses. Diarrhoea and pneumonia remain the two main causes of death among under-five children. More than one in ten children suffers from diarrhoea, which in turn exacerbates already high rates of stunting and wasting. Over 90 per cent of under-five deaths can be prevented through adequate nutrition, essential medicines and oral rehydration solution.
The main causes of maternal mortality are postpartum haemorrhage, infections, sepsis and other complications during pregnancy, with women who give birth at home most at risk. Maternal mortality ratio remain high at 65.9 per 100,000 live births. According to the 2017 MICS Survey, over 7.8 per cent of the deliveries occurs at home and account for nearly two thirds of all maternal deaths. The shortage of critical live-saving drugs, such as oxytocin (to treat post-partum hemorrhage and control excessive bleeding) and magnesium sulphate (used to treat pre-eclampsia) contributes to high maternal mortality rates. Poor nutrition, including anaemia, further contribute to reproductive health problems.
Tuberculosis (TB) is highly prevalent, at a rate of 641 per 100,000 people, one of the highest TB burdens in the world (with no HIV infection detected). Annually, around 110,000 cases of TB are detected, with an estimated 5,200 new multidrug resistant TB (MDR-TB) cases. There are an estimated 16,000 TB-related deaths each year10. Nutrition and smoking are contributing factors. Although some resources have been committed for treatment of TB, including for pediatric TB, there are significant challenges in sustaining pipelines for supplies without funding, increasing the risk of further transmission. Additionally, while the incidence rate of malaria is moving towards elimination, there are still 9 million people at risk of acquiring the disease. Without adequate medicines, achieving the last mile will be difficult, jeopardising the achievements already made and will pose a higher risk of an a resurgence of the disease which could spread across the country’s borders.
Therefore, intensifying timely diagnosis, initiating early and continuous treatment that ensures compliance can significantly reduce disease transmission, morbidity and mortality. Adequate funding for medicines, diagnostics and equipment will play a crucial role in addressing the significant health challenges in the country.
Declining conditions in water, sanitation and hygiene
While there has been some improvement in development indicators, as evidenced by improvements in stunting and wasting rates, as well as infant, child and maternal mortality, serious constraints in accessing safe drinking water, safely managed sanitation and hygiene services persist.
High prevalence rates of diarrhoea and other diseases, as well as the prevalence of undernutrition, are driven by the lack of safe water and sanitation facilities. According to the MICS data, 39 per cent, or estimated 9.75 million people, do not have access to a safely managed drinking water source, rising to 56 per cent in rural areas. Women overwhelming are responsible for collecting water (65 per cent), with the responsibility being shouldered by women more so in rural areas (72 per cent in rural areas compared to 61 per cent in urban areas). Amongst the most vulnerable households, 36 per cent of people, including 54.1 per cent of the rural population, are found to have contamination in household drinking water, placing them at increased risk of ill health. As a result, more than one in ten children suffers from diarrhoea each year which remains one of the top causes of deaths in the country.
Inadequate access to sanitation is further aggravating health risks. Around 16 per cent of people do not have access to even basic sanitation facilities, it is even fewer for rural areas with 29 per cent12. Nine out of ten people in rural areas, and three out of ten in urban areas, live in environments carrying potentially deadly health risks due to the unsafe disposal of human waste and the use of unimproved sanitation facilities13. There are also significant variances in access to safe drinking water and sanitation services in the different provinces.
DPRK is highly vulnerable to recurrent natural disasters. The IASC Index for Risk Management ranks DPRK 39 out of 191 countries in terms of disaster risk. Between 2004 and 2018, over 6.6 million people were affected by natural disasters such as drought and floods, compounding vulnerabilities, and increasing the need for assistance.
Floods and drought regularly strike the country in the same year, compounding already dire chronic humanitarian needs. These disasters cause displacement, destroy homes and critical infrastructure and disrupt supply chains. This impacts on household livelihoods and community resilience. These events also cause an increase in rates of disease, such as diarrhoea, and negatively impact on food security and nutrition.
In 2018, a heatwave in the middle of the year impacted crop production across the country, as temperatures soared 11⁰C above average. The heatwave was swiftly followed by flooding in several provinces in August. Following Typhoon Soulik on 23 August 2018, Kangwon and South Hamgyong provinces experienced heavy rains that affected around 60,000 people. Less than a week later, North and South Hwanghae provinces were hit with flash floods, affecting over 280,000 people, killing at least 76 people and displacing around 11,000 people. A total of 1,758 houses and 56 public buildings, such as schools and health clinics were either damaged or completely destroyed.
Agricultural production continues to be severely affected by natural disasters, eroding coping capacities of farmers. Even relatively small-scale events can have serious impacts on food production. For example, the August floods destroyed 17,000 hectares of arable land and damaged fish farms and livestock, contributing to reductions in end of year harvests, aggregating an already precarious food security situation.
While the Government has capacity to respond to disasters and has taken a lead role in responding to the August flood events, especially in rescue operations and the reconstruction phase, international humanitarian assistance continues to play a vital role in emergency preparedness and in response efforts in the immediate aftermath of a disaster.
Operational challenges and constraints
The geopolitical situation related to DPRK remains fragile and difficult to predict. While Security Council sanctions imposed on the country clearly exempt humanitarian activities, humanitarian agencies continue to face serious unintended consequences on their programmes, such as lack of funding, the absence of a banking channel for humanitarian transfers and challenges to the delivery of humanitarian supplies.
The banking channel, used to bring funds into the country to pay day-to-day operational costs has been suspended since September 2017. Attempts to find a replacement channel have so far been unsuccessful. Despite this challenge, humanitarian agencies have continued to implement their activities. Some 90 per cent of humanitarian expenditure is undertaken outside the country. The relatively small amount of funding required in-country is largely to cover operational costs, including rent, utility costs and local salaries.
The welcome adoption of the Implementation Assistance Notice (IAN)19 Number 7 by the 1718 Sanctions Committee in August 2018 was a critical step towards streamlining and expediting exemption requests for humanitarian operations. Rapid application of the IAN, as well as expediting the review and approval of the exemption requests for humanitarian programmes will help to alleviate the suffering of hundreds of thousands of people.
However, the continued risk-averse approach taken by suppliers and some authorities in transit countries when dealing with the importation of humanitarian items into the DPRK continues to cause significant delays in the delivery of life-saving humanitarian assistance. Suppliers can also be reluctant to import items due to the heavy procedures, delays in port clearance, higher expenses and/or reputational risks. With the limited availability of suppliers, the costs to source items have also increased.
Funding for humanitarian operations has also declined significantly over the last five years. UN agencies and INGOs through the 2018 Needs and Priorities Document appealed for US$111 million to meet the critical life-saving needs of six million of the most vulnerable people. The appeal was only 24 per cent funded, one of the lowest funding levels in 10 years and one of the lowest funded appeals in the world. The low level of funding is impacting operations. In the Nutrition Sector, fortified food assistance to 190,000 kindergarten children was suspended due to a lack of funding. In the WASH Sector, partners to the Needs and Priorities reached 101,000 beneficiaries of the 357,000 people targeted (around 28 per cent). Including other partners, an additional 53,000 were reached. However, the delivery of safe drinking water projects has not been completely implemented for around 229,000 people in part due to a lack of funding as well as delays in sanction exemptions clearances.
Facing the above mentioned challenges, agencies have been forced to scale back essential programming, thus seriously compromising the delivery of basic humanitarian interventions that are crucial to safeguarding the lives of the most vulnerable. However, further cuts to programming could roll back access gains and exacerbate the already dire humanitarian needs faced by the most vulnerable people in the country.