Situation Analysis of Women and Children in the DPRK

Children and Women in the DPRK: A Situation Analysis 1999 Executive summary This report analyses the situation of children and women in the DPRK in 1999. The first section

identifies the national context which shapes the opportunities and possibilities for survival, growth,

development, protection and participation rights for children and women in the DPRK. It reviews some of

the economic, political and social factors that provide the framework in which children and women live and

work. Section two evaluates the historic achievements of the DPRK in its social provisions and evaluates

how the DPRK’s social infrastructure has been affected by the economic crisis of the 1990s. This section

focuses specifically on how health, nutrition, education and water, environmental and sanitation services

have been affected. Most specifically, it focuses on how the child’s right to survival, growth and

development have been threatened by the breakdown in public and social provision. The situation analysis

finds that around two thirds of the child population in DPRK are stunted (low height for age) and that every

sixth child is suffering from wasting (low weight for height). There is no indication that the high incidence

of malnutrition in the child population is substantially diminishing overall. There is some indication, by

contrast, that international assistance is contributing to the diminution of acute malnutrition of children who

regularly attend children’s institutions.

The third section utilises the information provided in sections one and two to further analyse the

situation of children and women by using a life-cycle analysis. The differing affects of the crisis on

different age groups of children are further evaluated. Section four summarises trends, areas of concern and

offers a list of strategic priorities for action. These strategic priorities emphasise that an integrated, multi-

sectoral strategy should continue to be developed in order to cope with a situation which demands both

emergency assistance and more long term development work with a greater focus on the preventive

aspects.

The Situation Analysis uses an explicit conceptual framework drawn from the child rights

approach outlined in the text.

Children and Women in the DPRK: A Situation Analysis 1999

Executive summary List of contents Introduction Preface: Methodology and the data issues i methodology ii the data issues Section 1 The National Context 1. Demography and geography 1.1 Population 1.2 Urbanisation 1.3 Topography and climate 1.4 Consequences of demographic and geographical factors 2. The Economy 2.1 Overview 2.2 Agriculture and food supply 2.2 i Food self-sufficiency 2.2 ii The cooperative farms 2.2 iii Individual production 2.2 iv Food supply 2.2 v Consequences of changes in agricultural production and food supply 2.3 A Complex economic infrastructure: industry, transport, communications, energy and trade 2.3 i Self-reliance 2.3 ii Industry, transport and communications 2.3 iii Energy 2.3 iv Trading partners 2.3 v Consequences of the deterioration of the industrial infrastructure 2.4 Public infrastructure 2.4 i Consequences of the change in public infrastructure capacities 2.5 Consequences of economic change 3. The Polity 3.1 The Korean Workers’ Party 3.2 Organisation and ideology of the party 3.3 The 1998 constitution 3.3 i Policy change 3.4 Consequences of change in the polity 4. Society and Culture 4.1 Collective organisation and the Juche philosophy 4.2 The national culture 4.3 Institutional aspects 4.4 Consequences of societal organisation 5. External political environment 6. Future scenarios 7. Growing partnerships 7.1 The UN agencies 7.2 The non-governmental organisations 7.3 Developing cooperation 7.3 i Continuing difficulties 7.4 Consequences of international humanitarian partnership

8. Framework of Analysis: the Rights of the Child Section 2 The Policy Framework 1. Introduction 2. The rights of the child 2.1 CRC and the National Plan of Action 2.2 National Plan of Action (NPA) – objectives i Health ii Maternal health and family planning iii Nutrition iv Education v Water, environment and sanitation 3. Health 3.1 Introduction 3.2 The health system 3.2 i The national health care system: structure and functions 3.2 Staffing and training 3.4 Strengths and weaknesses of the health care system 3.4 i Infant mortality 3.4 ii Low birth weight 3.4 iii Maternal health Diagram of national health care structure 3.4 iv Maternal mortality 3.4 v Disease 3.4 vi Immunisation 3.4 vii Functioning of health institutions 3.5 Summary 4 Nutrition 4.1 Introduction 4.2 The nutrition infrastructure: the distribution system and children’s institutions 4.2 i Children’s institutions 4.3 Staffing 4.4 The nutritional situation in the DPRK 4.4 i The pre-crisis situation 4.4 ii Changes in the mid-1990s 4.4 iii A malnourished child population 4.4 iv Scale of malnutrition and the necessity for universal intervention 4.4 v Micronutrient deficiency 4.4 vi Breast feeding and complementary feeding in the DPRK 4.4 vii Stress and the care-takers 4.4 viii Food distribution and supply 4.5 Summary 5 Water, environment and sanitation (WES) 5.1 Introduction 5.2 The water, environment and sanitation infrastructure 5.2 i Water supply 5.2 ii Sanitation 5.2 iii Hygiene 5.3 Staffing 5.4 Strengths and weaknesses of the WES systems 5.4 i Water 5.4 ii Environment and Sanitation 5.4 iii Disease and diarrhoea

5.4 iv Hygiene 5.4 Summary 6. Education 6.1 Introduction 6.2 The education infrastructure: institutions and curriculum 6.2 i Structure and curriculum 6.2 ii Children in need of special protection measures 6.3 Staffing and training 6.4 Strengths and weaknesses of the educational system 6.4 i Coping with the crisis 6.4 ii Orphanages and boarding schools 6.5 Summary Section 3 Living in crisis: the child in the DPRK 1. Introduction 1.1 Child survival, growth, development, protection and participation in the DPRK 1.1 i Service provision: foundations, challenges and possibilities 1.1 ii Differences in children’s experiences 1.1 iii Table: Survival, development, protection and participation: threats and causation 2. The first year of life 2.1 Introduction 2.2 Survival 2.2 i Prior to the crisis 2.2 ii The 1990s 2.2 iii Low birth weight 2.2 iv Food supply 2.2 v Malnutrition 2.2 vi Inadequate health care 2.3 Development and protection 2.4 The orphaned child 3. From 12 months to 5 years old 3.1 Introduction 3.2 Survival 3.2 i Prior to the crisis 3.2 ii The 1990s 3.2 iii Food supply 3.2 iv Malnutrition 3.2 v Inadequate health care 3.2 vi Care practices 3.2 vii Slipping through the ‘net’ 3.3 Development and protection 4. The older child – from 6 to 12 years old 4.1 Introduction 4.2 Development and protection 4.2 i Prior to the crisis 4.2 ii The 1990s 4.3 Survival 5. Adolescents and youths 5.1 Introduction 5.2 Development and protection 5.2 i Prior to the crisis 5.2 ii The 1990s 5.3 Survival

6. The adult – women and mothers 6.1 Introduction 6.2 Development, protection and participation 6.2 i Prior to the crisis 6.2 ii The 1990s 6.3 Survival Section 4 trends, areas of concern and strategies for the future 1. Trends 1.1 The prevalence of child malnutrition 1.2 From 1998 to 1999: changing priorities 1.3 The macro-level 2. Areas of concern * Data collection, collation, systematisation, analysis and dissemination * Continued child acute and chronic malnutrition * children’s residential institutions * Support of women and mothers 3. Strategies List of sources

Children and Women in the DPRK: A Situation Analysis 1999 Introduction UNICEF began its activities in the DPRK in 1985 and established a resident presence in 1995 after the government requested international assistance to cope with the damage caused by widespread floods. Following the severe hailstorms of 1994, flooding took place in 1995 and 1996, followed by drought and tidal waves in 1997. These natural disasters with their severely deleterious consequences for children and women were the reason for the initiation of an extensive UN emergency programme in the DPRK from 1996 onwards. UNICEF, along with the WFP and UNDP, has taken a lead operational role in both the provision of humanitarian assistance and the coordination of international assistance from the UN system and the non-governmental organisations. The initial humanitarian effort was based upon providing a speedy response to the apparent and immediate threat to life of children and women because of lack of food and medical supplies and appropriate heath care. Together with the government of the DPRK, the international community made an intense effort to organise and distribute food aid to those in greatest need – particularly children under six years of age, pregnant and nursing mothers and hospital patients. By 1999, the focus of the international humanitarian involvement in the DPRK had shifted from dealing with immediate and urgent threats to life to the more diffused dangers to life presented by an increasingly visible complex humanitarian crisis. The threat to life for children and women in 1999 involves the related issues of economic decline, lack of resources to maintain the socio-economic infrastructure, consequent break down in health, water and sanitation services, knowledge gaps due to an isolation from developments in contemporary care practices and continuing poor nutrition due to insufficient and inadequate food intake. The humanitarian effort must not only deal with immediate threats to mortality but assist in the development and consolidation of capacities such as to ensure that the child’s rights to survival, development and protection are sustained and consolidated.

An essential requirement for effective humanitarian work is the ability to assess both the scale and scope of need and the effectiveness of humanitarian programmes. There was very little reliable information about the DPRK available to the humanitarian community when it started operations in 1995 and this lack of a reliable knowledge base has handicapped the international assistance effort. Since it became established in the country just four years ago, the international community, in cooperation with the government, has had to rely to a large extent on its own efforts to collect and collate a knowledge base about the DPRK. The Situation Analysis for 1999, therefore, is based on the limited information available to the international community (inside and outside of the DPRK). It is nevertheless the product of ongoing collaboration with the government and the wider international humanitarian community. Since UNICEF, along with UNDP, has been both one of the longest established agencies in the DPRK, and is today at the centre of the humanitarian effort, the Situation Analysis also provides a picture of the situation of children and women in the DPRK in 1999 which is as accurate as possible given the knowledge available to the wider international community at this time.

Preface: Methodology and the data issues i methodology

The Situation Analysis of the DPRK in 1999 was prepared, researched and written in a three week period in Pyongyang between October 16 and November 7 1999. The 1997 and 1998 Situation Analyses of the DPRK were draft documents only. The Situation Analysis 1999 had only indirect input from the government through the information it had previously provided to UNICEF and other agencies for its operational purposes. The preparation of the situation Analysis 1999 therefore was constrained by a very tight time schedule, no previously finalised Situation Analysis on the country and lack of direct informational input from governmental ministries and agencies. The information base came therefore from the consultant’s own specialist research on the DPRK, documentation available from UNICEF and other organisations in the time period, and interviews in Pyongyang with UN, NGO representatives and others involved in humanitarian work in the DPRK.

A major constraint on the preparation of the Situation Analysis was the more general problems associated with data and information collation, analysis and dissemination in the DPRK. These are detailed below as they have broad implications for the planning and operationalisation of international assistance programmes in the DPRK.

The Situation Analysis is, however, based on the foundations of current international research on the DPRK, a now extensive series of policy documentation on the international community’s involvement in the DPRK and the professional experience of those working in the DPRK and in emergency situations elsewhere in the world. It therefore presents as accurate, reliable and systematic analysis of the situation facing children and women in the DPRK as is possible given the above constraints. ii the data issues

There has been some controversy about the difficulties in obtaining reliable socio-economic data about the DPRK. On the one hand the international humanitarian community requires data so that it can respond to need efficiently and so that it can measure the effectiveness of its assistance programmes. On the other hand the DPRK government has been concerned about the perceived intrusive nature of data collection – both at the level of the individual within society and at the broader political level. These occasionally conflicting concerns have sometimes made for misunderstandings between the partners. Despite these differences in viewpoints, the international community and the government have continued to work collaboratively to produce and disseminate a knowledge base that has provided a useful foundation for humanitarian work in the DPRK

Donor pressures on the international humanitarian community for assurances that food aid was reaching intended beneficiaries meant that initial data concerns after the inception of emergency programmes in 1995 focused on this issue. With monitoring procedures and practices well-established by 1999, the major agencies have concluded that there is no evidence of serious aid diversion. In some respects, monitoring of aid distribution in the DPRK is somewhat easier than in other countries as the personal safety of monitors is not an issue and there are no reports of pilfering of goods. Although supplies sometimes do go astray, probably because of hoarding and sharing within the wider local community, there is no indication of corruption. Hoarding is carried out because of the fear of future shortages. There is also evidence of inefficient and inappropriate use of some supplies, for instance, in the poor management of high energy milk and essential drugs, but this is again more due to insufficient training in its use than to deliberate abuse.

At the macro socio-economic level, useful data is available from UNDP and other international sources, for instance on trade statistics, GDP figures, participation levels in the workforce, etc. Also at the macro-level, the government worked closely with UNDP to produce a comprehensive study of the economic situation of the country subsequent to the damage caused by the natural disasters of the mid-1990s. This 1998 study provided the database for a set of proposals on agricultural recovery and environmental protection which have been accepted by both the government and potential donors.

There is also useful micro-social data available, some of which is based on the 1993 governmental census. Given the dislocations caused by the natural disasters of previous years – including deaths, homelessness, the rise in the number of orphans and destitute children and, given the likely disruption of domestic reporting systems, caution needs to be exercised in respect of this material. Reliable information

on the scale of need emerged from the 1998 joint government and international community nutrition survey and the government/UNICEF collaborative effort on the 1998 Multiple Indicator Cluster Survey (MICS) - also evidence of fruitful collaboration between the partners. Negotiations continue about future nutrition surveys and the international community hopes to continue collaborating with the government in order to regularise and systematise the survey approach in an effort to provide the best possible knowledge base to maximise the effectiveness of programmes.

In 1999, therefore, the international community has access to data from a number of sources including the government, a variety of international agencies including academic institutions, and from the 1998 joint DPRK government/international community surveys. It also has access to a now large number of field reports from UN agencies and NGOs. All these data sources could together provide the base of an understanding of the social environment of children and women in the DPRK. Not all information is reliable and there are difficulties in checking for accuracy. In addition, although there are regular fora for coordination and cooperation between the partners in the humanitarian community, efforts are needed to systematise collection, collation, analysis and dissemination of the increasing amount of information available from disparate sources. In 1999, therefore, attention is being paid to increasing the accuracy and reliability of current data in order to more effectively monitor of trends in terms of the scale and scope of need and the effectiveness of assistance. Efforts are being made to engage with the government to improve reporting systems in these areas. As the international agencies move into new areas of collaboration with the government in, for instance, capacity building in health and nutrition, information on current social and health care practices will be necessary for the partners to devise effective programmes. These will be particularly sensitive areas for international involvement given that they could involve perceived ‘intrusiveness’ in DPRK social and cultural life. The experience of now four years of effective collaboration between the international community and the government should, however, continue to provide a base for fruitful dialogue and partnership in these areas as they have done in other areas such as the nutrition and MICS. The process of dialogue between the government and the international agencies between 1994 and 1999 has led to improvement in terms of the quantity and reliability of information available so as to assist in the efficient planning and implementation of joint programmes. More dialogue will take place so that further progress can be made in this area.

Section 1 The National Context This section analyses the demography, geography, the economy, the polity, the society and culture of the DPRK in terms of the changes of the 1990s and the consequences of those changes for the well-being of children and women. It evaluates the strengths and weaknesses of the broader socio-economic environment in the context of the DPRK’s ability to implement the child’s rights to survival, development and growth, protection and participation. It therefore considers both achievements and the threats to child rights brought about most importantly through the economic crisis facing the country in the 1990s and the devastating natural calamities experienced in the mid-1990s. The section considers alternative possible scenarios for the child in the DPRK. It then reviews the growing partnerships designed to address challenges to the rights of the child in the DPRK. It concludes with an explicit formulation of the conceptual framework that informs the Situation Analysis.

1. Demography and geography

1.1 Population composition Based on projections drawn from the 1993 census, the population of the DPRK stands at around 23

million in 1999. The 1993 census indicates a sex ratio of 48.7 per cent men to 51.3 per cent women. Of the 7 million children aged under 18, just under 3 million are aged under 6 years. The growth rate of the population has shown a steady process of decline since the 1960s with the government figures of 2.8 per cent in the period 1965-1975, through to 2.5 per cent in the following decade, to 1.5 per cent in 1995 and 0.9 per cent in 1998. Government figures indicate an increase in mortality rates from 6.8 per thousand in 1995 to 9.3 per thousand in 1998. Population figures may not be wholly accurate in themselves, due to the problems in collecting and systematising population data in a time which has been marked by natural disaster and a breakdown in some aspects of social capacity, but what is significant is that they almost certainly accurately reflect a continuing downward trend in population growth.

The Korean population is one of the most ethnically homogeneous in the world with a very small minority population of just a few thousand ethnic Chinese. In 1985, the UN estimated that only 0.2 per cent of the population were born outside the DPRK. The relative ethnic homogeneity of the people no doubt contributes to the overall social stability but it should not be overplayed as a focus of analysis. Other countries (for instance Somalia) are as ethnically coherent yet they do not manage to achieve the degree of social integration displayed in the DPRK, particularly in times of national emergency. The population of the DPRK is also universally literate and because of the hierarchically structured social system which has prevailed for the last 50 years well-organised and disciplined. 1.2 Urbanisation

The DPRK is a highly urbanised country with an estimated 62 per cent of its population (14 million)

living in towns and cities. The 9 million residents in rural areas include some 2.6 million cooperative farmers and their families. Pyongyang, the capital city, is home to some 2.7 million people - just over 10 per cent of the national population. The western port town of Nampo is the next largest city (if one includes the outlying districts) with 730,000 inhabitants, followed by the Kaeson area (also including the outlying areas), situated close to the border with the ROK, which has 334,000 inhabitants. Other major cities include the border town of Sinuiju and the east coast towns of Hamhung and Wonsan. Population movement is controlled in the DPRK and only about five per cent of the population relocate each year with very little rural- urban mobility. This means, among other things, that the population figures for these cities (particularly in relative terms) are probably fairly accurate. There are some reports of population movements in search of food and income but these have not been seen on a large scale by the international community within the two-thirds of the country in which it operates.

1.3 Topography and climate Over 80 per cent of this scenically beautiful country is mountainous with 61 per cent of the land

forested. Only about 20 per cent of the DPRK land area of 121,800 square metres (47,027 square miles) is arable and used for crop production.

The DPRK is relatively isolated geographically - sharing borders with remote parts of China and Russia in the north and being completely cut off from the ROK by a military demarcation line in the south. Mountainous areas comprise much of the northern border - most of which is shared with China with the far north eastern frontier shared with Russia. The nearest major city in Russia to the DPRK is Vladivostock. Much of this northern border area is also not easily accessible from Pyongyang - because of the difficult terrain and the difficulties in respect to fuel and transport. The DPRK is separated from the ROK at the demilitarised zone (DMZ) at Panmunjon. The southern border area is heavily guarded by both countries (the DPRK and the ROK) and is impenetrable. The West Sea of Korea (Yellow Sea) and the East Sea of Korea (Sea of Japan) form the western and eastern frontiers of the DPRK.

The climate is temperate with four distinct seasons. The temperatures can reach extremes with January temperatures often falling well below zero and Summer average maximums at 27 degrees Celsius. Rainfall is concentrated in the Summer months with the highest average daily rainfall in August.

1.4 Consequences of demographic and geographical factors

One major consequence of the population structure is that DPRK society remains well-organised and

its leadership able to effectively mobilise for reconstruction. The combination of geographical isolation, political and physical separation (from the south),

difficult terrain and winter extremes of temperature has, however, contributed to five areas of concern in terms of today’s situation affecting the well-being of children and women. Firstly, the DPRK has been physically cut off from regular interrelationship with international developments in technology and scientific practice. Such interchange as used to exist was mainly with the former Soviet Union and Communist eastern Europe but these links were largely ended by the early 1990s. This means, for instance, that there has been no 'natural' sharing, for example, of changes in clinical and health care practices. Secondly, within the DPRK, there are some parts of the country which due to the difficult topography and climactic extremes, combined with problems of transport and communications due to the economic difficulties facing the country, are likely to be facing particular hardship in the context of overall national nutrition and health problems facing the entire country. Thirdly, the lack of arable land contributes to difficulties in the resuscitation of agricultural production. The fourth is that deforestation is occurring as the population looks for ways to grow more food, obtain fuel and earn income (through selling wood). This in turn contributes to more general environmental problems including the increased risks of renewed flooding. A fifth consequence is that the physical burden caused by the limitations of the natural environment, combined with the economic crisis of the 1990s, falls disproportionately on women. Many women are engaged in increasingly marginal agricultural production, and at the same time must carry an increased responsibility for child support as state provision deteriorates.

2 The Economy

2.1 Overview

The impact of the direct damage to the economy of the floods and drought of the mid-1990s

combined with the economic decline which started to become evident in the late 1980s is now well-known. The government estimated that $15 billion worth of damage was caused from the combined loss of food stocks and the harvests, destruction of infrastructure including irrigation facilities, roads, bridges, railroads and the affect on factories, mines and farmland.

According to figures produced jointly by the government and the UNDP, GDP declined by about 50 per cent between 1993 and 1996 - representing a drop in per capita income to $481. Acute food shortages caused by the floods exacerbated an underlying chronic situation whereby food had evidently been in short supply since the 'Eat Two Meals a Day' campaigns of the early 1990s. Food shortages and the parallel scarcity of health related supplies threatened the lives of millions of people, particularly the most vulnerable - young children, pregnant women and the elderly. From 1995, the international community responded to the requests of the government for assistance with food aid and related nutritional, health, water and sanitation, and education assistance. Many immediate needs were met and continue to be met by international assistance. At the same time there is still evidence of acute and chronic malnutrition in the population and the humanitarian community is finding difficulties in assessing the scale of need and the impact of assistance programmes because of some constraints in access to beneficiaries.

What is also not very well understood is the extent of economic recovery since the mid-1990s and the potential for full rehabilitation of the economy. On the one hand, international trade continues to decline as does per capita GDP and GNP and necessary inputs, such as food and fuel, continue to be provided by way of assistance from abroad. On the other hand, the government, in cooperation with international partners such as UNDP, has initiated policies to encourage foreign investment in agriculture, industry and trade sectors. Some foreign investment is taking place through joint ventures - particularly in the Rajin-Sonbong free trade area in the north-east and the Pyongyang/Nampo region. In addition international donors have offered assistance to help rehabilitate agricultural production. There has been a recovery in rice production in 1999 but the maize harvest is reported to be 30 per cent lower than 1998.. Some industrial units are back in production, some coal-mines have been rehabilitated and some joint ventures have been agreed with business from the ROK and Japan.

There is also a growing domestic ‘private economy’ in both the rural and urban areas which might indicate declining governmental revenues are being set off by private trade. The creation of a ‘private’ trade sector has been apparent from at least the early 1990s, for instance in clothes making and hairdressing, but the petty trading activities developed as coping mechanisms to respond to food and basic needs requirements in the mid 1990s have expanded this sector. They have also contributed to a legitimation of this sector as something which is, at least in the short to medium term a prevailing feature of the economic landscape as the ‘private economy’’ expands and is condoned, sometimes encouraged, by the government.

The government has also instituted what it calls the ‘second Chollima movement’. This is a campaign to harness human resources to find innovative and collective says to respond to the economic problems facing the country. The intention is to maximise the people’s efforts to find short-term solutions while the government sees medium term and long term answers through effective diplomacy with external economic and political actors. The campaign demonstrates a very strong organisational capacity of the society and the government. At the same time, it depends on very low technology and high physical inputs at a time when food shortages and health service deficiencies mean that there is little spare energy available for such exertions.

The government expects that the implementation and consolidation of its policies, which include the encouraging of foreign investment and the introduction of a limited private sector, should create the foundation for economic recovery. Although the government hopes to be self-sufficient in the production of basic grains by 2001, it is still expected that food imports would be needed to supplement domestic food production. This will therefore mean that the DPRK’s export capacities will need to be revived, in order to generate the necessary foreign exchange to purchase food and other inputs. A return to sustainable economic growth would necessarily diminish and eventually eradicate the need for humanitarian emergency input, and facilitate the return to more regular programmes of cooperation with the DPRK.

2.2 Agriculture and food supply The DPRK has historically aimed to achieve food self-sufficiency. The aim of the government's post

1995 agricultural policies, developed in conjunction with UNDP, and endorsed by international donors, is to resuscitate agricultural production in order to achieve self-sufficiency in food grains by 2001. The parallel plans for economic recovery envisage that foreign exchange earned from trade could be used to pay for future necessary food imports. The government has thus a clear strategy and plan which involves moving away from aid dependency for food supplies.

2.2 i Food self sufficiency

Historic and intended food self-sufficiency policies are founded on an agricultural production system

where the 3000 cooperative farms have accounted for nearly 90 per cent of agricultural production. Cooperatives produce the basic cereal requirements of the country - predominantly rice and maize although potato is becoming an increasingly important crop. The intention is that the cooperative farms provide for the nation's food security. The cooperative sector is supported by the 1000 or so state farms whose specialist functions have included poultry farming, livestock production, seed production and fruit and vegetable cultivation.

2.2. ii The cooperative farms

Just as national agricultural policy aimed for food self-sufficiency, so it also aimed for self-

sufficiency, in terms of food production and social organisation for each cooperative farm. Cooperative farms provided basic health, education and cultural services as well as employment. The aim was to consolidate social and organisational cohesion as well as the efficient production of food. To assist in the promotion of the former objective, cooperative farms, which can encompass between 10 and 20 small villages, are located more or less in line with the boundaries of the Ri (the lowest level of county administrative organisation) with each county having about 20-30 cooperative farms. The Ri is based on very longstanding social and kinship networks. Thus cooperative farm organisation is held together by some very strong historically founded social ties of obligation and responsibility. Agricultural production also relies heavily on the mass mobilisation of students, the militia and urban workers at rice-transplanting, planting and harvestng times. This 'social assistance' has both an economic and a social function as it reinforces the interdependence of rural and urban populations, students and workers, in a visible expression of national self-help and purpose.

Cooperative farms have historically been allowed a certain amount of autonomy within the context of the overall national plan. Since the mid-1990s, cooperative farms have been further encouraged to utilise and expand their freedom of action to find innovative ways of responding to the crisis. This has permitted, among other things, a liberalisation in trade as farmers with surpluses buy and sell on markets outside the state system.

2.2. iii Individual production

Agricultural production is further supported by individual production in the rural and urban areas.

Farm families are permitted small individual plots of land where vegetables and soybeans are produced and small animals raised, such as rabbits and poultry. Individuals also produce small amounts of food by using balconies and available land to keep animals and grow vegetables. Communities, enterprise and institutions in urban areas are encouraged to make use of every spare piece of ground, including flat rooftops and road verges that can be used for food production. Individuals, legally and semi-legally, engage in private domestic trade - in some cases engaging in border trade in the northern most part of the country.

2.2. iv Food supply

Food supply is organised through the national Public Distribution System (PDS). Excepting

cooperative farmers and their families who receive food directly from their own harvests, the entire population is supposed to receive food through the PDS. The system used to provide all basic necessities to the population based on a scale relating to needs entitlements. Children received food through the family ration as well as through the food ration allocated to the institutions they attended. The PDS came under enormous

stress in the 1990s with daily entitlements to food gradually cut. In addition some cooperative farms could no longer grow enough food to fulfil consumption requirements. International food aid is channelled through the PDS - and World Food Programme monitors confirm that aid is reaching intended beneficiaries in children's institutions, hospitals as well as elderly people and pregnant women and nursing mothers. Some food aid is also reaching farming families through food for work schemes.

A November FAO/WFP crop assessment mission found total grain requirements for 99/2000 amount to 4.76 million. It found that there would be a cereal deficit of 1.29 million tonnes in 1999/2000. Food aid requirements would amount to just under one million tonnes. Further urgent assistance would be required to provide protein, fats and oils. Despite higher harvests of rice in 1999, maize output fell by 30 per cent.

The government continues to work with international partners to rebuild its agricultural sector as cooperative farms have not recovered from the chronic and acute economic problems of the 1990s. Given the continued downturn of the economy in trade and GDP terms and the continued reliance on the international community for basic supplies, it is also unlikely that the PDS serves as an effective instrument of national redistribution of food and essential supplies such as fuel for heating. Continued reports from NGOs, including those coordinated through the Food Aid Liaison Unit (FALU) and individual agencies such as ACF, of malnourished children 'slipping through the net' suggest that the PDS may not have recovered its former ability to sustain secure provision of basic supplies to all communities.

2.2 v Consequences of changes in agricultural production and food supply

A major consequence for children and women of the damage to the nation's agricultural capacities is

the lack of a secure food supply. The government has made agricultural reconstruction a major priority but implementation of these plans will take some time. Another consequence is the lack of a secure supply of adequate food - for instance food which would provide a balanced diet with the appropriate range of vitamins and minerals. Some individuals and communities have responded through coping strategies which include the expansion of private trade. Some individuals have attempted to cut into forest lands – both to provide land for growing food and in order to sell wood to obtain income. One consequence of changes in the agricultural production system then is deforestation and potentially damaging affects on the environment.

Many individuals and families, however, rely on international assistance. According to field reports, the most serious consequences including the threat of death face those who, for whatever reason, have not managed to obtain secure access to food and other basic supplies such as heating, medicines and safe water and who no longer are guaranteed state rations. Conditions are likely to be most difficult for those in remote areas – lacking food, heating and basic supplies in a country where winter temperatures in the northern mountainous areas are severe. 2.3 A complex economic infrastructure: Industry, transport, communications, energy and trade

DPRK economic planners developed an economic structure and strategy designed to provide for

self-reliant economic growth in order to meet both basic and more advanced needs of the population. The economy is based on the technological development and increased capacity of heavy industry. The economic structure displays a complex pattern of linkages across sectors, for example agriculture and industry, the raw materials sector and the manufacturing sector, domestic production and external trade. When the natural disasters struck in the mid-1990s, then, damage and lack of capacity in one sector had direct and deleterious effects in other sectors of the economy. The interrelated economic decline, natural disaster and loss of trade partners in turn affected a complex, interrelated economy such that damage to one sector had a visible and in turn damaging affect on other sectors. By 1999, there remained uncertainty as to the extent of the investment needed to rehabilitate the industrial infrastructure. The government, however, continues to make strenuous efforts to encourage foreign investment and is actively engaged in talks with the IMF, the World Bank, the Asian Development Bank and individual foreign businesses such as Hyundai from the ROK

2.3.i. Self-reliance

Since the creation of the state in 1948, the DPRK’s economic growth strategy has been based on

the development of heavy industry to provide capital goods for the rest of the economy including agriculture and light industry. The idea was to promote self-reliance so as not to be dependent on foreign

countries for equipment, raw materials, technical personnel and capital. Machine-building formed the central pillar of the industrial strategy so as to promote technological innovation in industry and to provide equipment for agriculture, transportation, postal and telecommunication services and the building industries. The country developed a successful electricity generating capacity – based on imported fuel, indigenous coal supplies and its own hydroelectricity capacity. Electricity capacity supported domestic, industrial and agricultural sectors with irrigation networks dependent on electrical pumping facilities. The DPRK developed a major cement producing capacity – for domestic construction of residential, industrial, agricultural and public facilities as well as for export. Among other things, the DPRK produced chemical fertiliser so as to provide the necessary inputs to allow for intensive cultivation of the limited arable land. The cotton goods industry permitted local production of clothes for both domestic consumption and export.

2.3.ii Industry, transport and communications

There have been repeated reports of large industrial plants, particularly steel works, standing idle

although it is also reported that production continues in some sectors. Fertiliser production is being resuscitated with the aid of foreign investment. Bottlenecks continue such as the absence of transport equipment and equipment for agriculture. Physical communication is by road and rail with a limited use of air transport. Although there are reports of long delays in train journeys and the west-east road routes are sometimes difficult because of the constant repair and maintenance work necessary to keep the road tunnels serviceable, yet there have been some achievements in communications infrastructure. In 1995 the main freeway between Sunuiju and Pyongyang was completed – following on from the completion of the Pyongyang-Panmunjon highway in the early 1990s. Domestic and overseas telecommunications services and facilities are rudimentary and expensive with restricted access to the internet and email facilities. The lack of access to electronic communication facilities is likely to be a handicap in the pursuit of joint venture foreign investment. It also has an impact in the provision of public services in that a potential channel of information on developments in good practice in health and social care remains closed to care workers and social and health policy makers in the DPRK

2.3.iii Energy

Like any modern economy, the DPRK relies on a steady input of fuel supplies to provide energy for

its industrial, agricultural, commercial, military and residential sectors. Fuel has included indigenous coal and hydroelectricity, imported oil and locally produced biomass (including wood and crop wastes). The DPRK is developing a nuclear power capacity and there has been some discussion of potential oil reserves in West and East Seas. DPRK energy planners have also expressed some interest in developing wind power projects.

Before the natural disasters of the 1990s, electricity was provided by a more or less equal combination of hydroelectric and coal-fired plants but by 1996, coal was providing the majority of the electricity generation in the DPRK. There are reportedly around 500 electricity generation facilities in the DPRK, with about 62 operating as part of the national grid. Of these 62, 42 are hydroelectric and reports indicate that up to 85% of their capacity could have been affected by the natural disasters. Two of the 20 major thermal power plants are fuelled by oil. Again, since the natural disasters, some of the coal fired stations have been assisted by inputs of imported oil.

Heavy industry is by far the biggest consumer of electricity in the DPRK and. although the overall level of national electricity consumption has been reduced since the 1990s, it is thought that relative proportions of electricity consumption stay the same. Widespread power cuts were reported in 1997 but it has been estimated that the cutback in heavy industrial production since the crisis of the mid-1990s has released more electricity for domestic and public consumption, therefore making power cuts less of an issue, at least in the centres of urban activity.

The problems in the energy sector include lack of spare parts, lack of testing equipment, no indigenous oil supplies, severe damage to hydroelectricity capacity, low level of technology (which leads to inefficiencies in production, damaged equipment, flooding in the coal mines, inadequate maintenance on rail lines (affecting the movement of fuel around the country) and waste due to inadequate infrastructure within the power industry. Lack of adequate insulation in home and buildings also results in wastage of energy generated. It is very likely that households and institutions in outlying parts of the country are very vulnerable to electricity cutoffs. International field workers report lack of heating in some of the children's institutions and health facilities in the winter.

A new national strategy is being adopted that encourages counties and ris nationwide to establish small-scale power plants, fed by local streams and rivers. However, it is not clear how schools and children’s institutions will benefit, given the large number of enterprises competing for the limited amount of electricity thus generated. 2.3.iv. Trading partners

Self-reliance did not mean a complete cutting off from cooperation with overseas trading partners.

Necessary raw materials, including importantly oil supplies, and inputs which could not be provided from domestic sources were obtained from trading partners in the Socialist bloc. Some efforts were also made to purchase western technology in the 1970s with loans from western sources - with the expectation that exports of raw materials would be able to fund debt repayments. When commodity prices fell in the late 1970s, the DPRK could not repay the debt. The debt has remained unpaid – resulting in the DPRK being unable to make further borrowings in international financial markets. Loss of trading partners and reduced international prices and markets, combined with the impact of the natural disasters of the mid-1990s resulted in a fall in overall trade volumes from nearly 5 billion dollars in 1990 to just under 2 billion dollars in 1996 to just under half a billion dollars in the first half of 1999

Change in trading partners has included a fairly rapid development of trade with the south. Trade between the DPRK and the ROK rose 77.9 percent to US$257.96 million in the first nine months of 1999, from US$144.99 million in the same period in 1998. This volume of trade was the largest ever for the January-September period since the two countries started trading in 1989. The rise is due to an increase in non-commercial transactions, including the nuclear reactor project, tourism projects at Mt. Kumgang, and food aid. Non-commercial transactions rose 206.3 percent to US$130.37 million for the nine months, from US$42 million in the same period a year earlier. Commercial trading grew 24.5 percent to US$127.58 million from US$102.43 million a year earlier. The ROK’s imports from the DPRK increased 24.8 percent from the previous year to US$79.9 million, while exports to the DPRK rose 119.7 percent to US$177.9 million, compared with US$81.0 million a year earlier. The rise in importance of the south as a trading partner for the DPRK may contribute to an easing of political tensions between the two countries.

2.3.v Consequences of the deterioration of the industrial infrastructure

The DPRK is not currently able to meet its food needs and to maintain its public services from its

own resources. Neither does the DPRK have access to foreign exchange with which it could purchase basics such as food and medical supplies as well as inputs into the wider economy. If it cannot borrow or receive substantial grant aid from western financial institutions, which is unlikely in the near future, it must rely on the regeneration of its export capacity so that it can earn hard currency. The country’s ability to feed itself and to meet basic needs without the support of the international humanitarian community will thus depend to a large extent on its capacity to encourage foreign investment and to revive its export sectors.

2.4 Public infrastructure

The DPRK had used its success in cement production to provide the material for the construction of

physical infrastructure including rural and urban residential housing, education and health institutions, and industrial and agricultural infrastructure such as reservoirs and dams. Each province produced building materials necessary for local housing construction and large enterprises and institutions were encouraged to use ‘spare’ materials and voluntary labour to build additional housing. Residential housing in urban areas, and to a certain extent in rural areas, is mainly in apartment blocks which are built around courtyards that are provided with children’s play equipment. The construction of new homes continued through the 1990s although the construction sector as a whole saw a continuous drop in output. One of the problems was that although cement remained available other necessary inputs, for instance glass for window panes, were not readily available. Another consequence of the lack of additional inputs was that maintenance of public infrastructure was problematic. Observations in the field indicate that some children’s institutions have been without glass in the windows.

2.4. i Consequences of the change in public infrastructure capacities

The DPRK’s achievements in the building of public infrastructure have been impressive. The commitment to the prevention of homelessness and the implementation of policies which continue to build homes in a time of great adversity is commendable. The major issues for the public infrastructure which have a deleterious affect on the well-being of children and women in the DPRK is the problem of maintenance. Buildings without proper insulation, deteriorating water piping, rundown buildings are partly a product of insufficient material inputs and diversion of human capacity on activities which have had to directly respond to flood related damage and the necessity to find ways to meet basic needs such as the provision of food.

2.5 Consequences of economic change

The DPRK made many advances for its citizens based on the development of a self-reliant national

economy. One of the durable achievements of the economy is the lack of homelessness and the continued ability, despite all the problems, to supply electricity to large parts of the country. Another achievement had been the provision of safe water supplies, although both quality and quantity of safe drinking water and safe human waste disposal have now become serious concerns for the government. The loss of trading partners in the early 1990s, the acute shortage of hard currency and the damage caused by the natural disasters of the mid-1990s combined to cause enormous damage in every part of what is a complex, interlinked modern economy. The DPRK government has responded with policy development to rebuild in agriculture, industry and foreign trade and investment. Some of this rebuilding will necessarily take time. In the meantime it is likely that there will continue to be large pockets of vulnerability, in terms of areas of the country and in terms of those groups of people who do not have access to food, heating, medicines and whose water, sanitation and general environmental conditions have deteriorated.

3. The Polity

The polity has changed in important respects in the 1990s. The death of President Kim Il Sung in

1994 and the subsequent crisis of the mid-1990s, combined with the uncertain international environment, has meant a steady pressure on DPRK decision-makers to respond to major domestic and international change. The process of political readjustment was consolidated in amendments to the constitution agreed on September 5 1998 in the first session of the tenth Supreme People's Assembly (SPA) which is a parliamentary institution. The SPA had not met since April 1994 and its five year term of office expired in 1995, so the country had been without a parliamentary body for three years. The reinstitutionalisation of political structures is therefore itself some indication of a 'normalisation' process within the polity.

3.1. The Korean Workers' Party

The dominant party, the Korean Workers' party (KWP) is still the most important political force in

conjunction with the military. His Excellency Kim Jong Il was appointed Secretary-General of the KWP on 8 October 1997. The party's Central Committee has responsibility for, among other things, the extremely important issue of north south (Korean) relations. The Military committee of the party directs the country's armed forces. The party is a mass as opposed to a vanguard party with a membership of around 3 million in 1989. This figure represents about 20 per cent of the adult population - and probably a much higher percentage of the adult male population.

3.2. Organisation and ideology of the party

The party organisation is organised in such a way that the leadership has a preponderant role in

strategic planning and key national decision-making. The party ideology differs from a Marxist-Leninist approach in that it argues that although it is important to develop the productive capacities of the nation as a base for building socialism, the party equally stresses the voluntary capability of the individual acting collectively as the means to achieve socialism. This policy of Juche or self-reliance, therefore emphasises a policy of what it calls the ‘intellectualisation’ of the entire population – prioritising education as a means to achieve the self-fulfilment of the individual in the context of building the nation.

3.3 The 1998 constitution

The socialist constitution which was adopted in 1972 gives the Korean Workers' Party (KWP) the

dominant political role in the country. This is conceived of as a steering role with the party providing general guidance and the state officials operationalising these guidelines. The 1998 constitution repeats this formula. The 1998 constitution formally locates political power in the DPRK within three institutions. These are the National Defence Commission, the Presidium of the Supreme People’s Assembly (SPA) and the Cabinet. There is no longer a presidential office. Instead the late president Kim Il Sung is entitled the Eternal President of the DPRK. His political successor Kim Jong Il was elected president of the National Defence Commission (NDC) which has a high status within the new constitution. The former minister of foreign affairs, Kim Young Nam, was elected as the President of the Presidium and it is the President of the Presidium who represents the state. The Presidium of the SPA is responsible for foreign affairs. The Cabinet has replaced the old State Administrative Council and it is expected to become closely involved in the management of the economy and the administration of the country.

3.3. i Policy change

The new constitution reflects de facto changes in the organisation of the economy and to some extent

legitimises them as well as seeks to control their expansion and direction. Non state entities may now own businesses and engage in trade. The new constitution specifies that socialist cooperative groups may engage in these activities. These include the party itself (KWO), the General Federation of Korean Trade Unions, the Agricultural Workers Union and the Kim Il Sung Socialist Youth League. These entities already engage to a certain extent in ownership of business and limited foreign trade. The new constitution legitimates small scale

private farming and limited private business ownership and development. Greater autonomy in factory management is stressed as is the concept of profitability

3. 4 Consequences of changes in the polity

There have been no major changes in the political infrastructure or in strategic policy direction. The

country is still committed to a policy of self-reliance and to a rebuilding of the socialist society. Within that context, however, policy change has come about in the encouraging of local autonomy to help find solutions to the nation’s economic problems. Institutions and increasingly individuals are being encouraged to find local solutions to filling the gaps in state provision. The ideology of the ruling party has continually stressed the value of education and one consequence of such a policy is that the DPRK is fortunate in having a literate, educated population which is well-placed to respond dynamically to the changing circumstances of the country. The negative aspect of the commitment to voluntary work as a solution to the nation’s problems is that the continuing demand for physical labour as a response to the emergency and this, combined with a lack of food and adequate health care, is likely to have contributed to exhaustion and possibly apathy in some of the population.

The new constitution reflects an institutionalisation in the movement to allow small scale market solutions to some of the problems facing the economy. The new constitution and the elections to the various new institutions of the state also reflect a political re-institutionalisation and regularisation of state affairs in the aftermath of the disturbances to the system caused by the death of the late president Kim Il Sung and the natural disasters of the mid-1990s.

4. Society and Culture

The salient point for an understanding of the DPRK's society and culture is the collective

organisation that permeates every aspect of society. Children, women and men are organised inside and outside the workplace in community groups whose responsibility it is to help build the nation. Many achievements were made through the collective organisation of society as the nation built health, education and childcare facilities - eradicating illiteracy and sharply increasing life expectancy rates. When natural disasters hit the country in the mid-1990s, the country could therefore rely on an organised, committed population to help in reconstruction. At the same time, this was an organised population which had already been participating in physically demanding work over a long period of time. Extra physical demands on individuals, combined with poor nutrition, food shortages and a collapsed health infrastructure are posing serious threats to health and well-being. Women were particularly at risk because as the primary care-takers in the society, they have carried the multiple responsibilities of finding ways to continue working for income, helping in collective activities such as harvesting, and caring for children.

4.1 Collective organisation and the Juche philosophy

The country's policy of collective organisation stems from its underlying Juche philosophy. This

philosophy stresses the infinite creativity of the individual working collectively to overcome any obstacle to social, economic, political and cultural development of the individual, the society and the nation. The individual is encouraged to developed their capacities - but in the context of the well-being of the collective and under the guidance of the leadership of the society. The entire social and political organisation of the country is organised around this principle. In practice, this means that individuals become members of the various organisations of society (children, youth, women, trade unions, etc) and through these organisations participate in nation-building tasks. For adults, much of this work involves a heavy physical contribution to, for instance, constructing roads or harvesting crops. The work is voluntary in that it is unpaid monetarily but whose reward is in contributing to the development and consolidation of national capacity. The DPRK has been literally built through the voluntary physical effort of the population building roads, dams, houses and infrastructure. This work takes place on top of the normal working day. In addition, agricultural production, planting and harvesting is dependent on the influx of voluntary labour as students, the military and anyone else who can be spared from the workplace emigrate temporarily to the countryside. Women, who have been incorporated into the workforce in very substantial numbers, fully participate in these nation-building tasks. They have been supported by the provision of nationwide children's institutions. In recent years, as provision

by the state has been less reliable due to economic constraints, women appear to be facing extra stress as they have to cope with the demands of work, any extra tasks required of them and the responsibility of child care.

4.2 The national culture The DPRK's national culture stresses a long, uninterrupted national heritage of 'Koreanness'.

Historical sites and artefacts are preserved and respected. A strong commitment to Korean nationalism which includes the whole Korean people (including those living in the south) is reflected in the promotion of a distinct Korean identity articulated through all aspects of cultural life - in art, sculpture, literature, film, dance, music and sport. It is not uncommon for Korean women to wear the national dress - particularly on national holidays and at festivities. Children are taught about the historical identity of the Korean nation as well as the more recent history of the creation of the state under the leadership of the late president Kim Il Sung. Cultural development is seen as an integral part of the educational process and all children are encouraged to sing, to learn to dance (female children particularly), to play music and to engage in sport.

4.3 Institutional aspects

The extensive and nationwide provision of institutions for children had meant that children could be

educated and receive steady supplies of food and care. In addition, women were encouraged to both enter into the workforce and take part in the wider society in a way which they had never been able to do prior to the creation and development of the DPRK's system of society. Children received basic care and education and were introduced to cultural activities in the children's institutions - fostering a commitment to the nation from an early age. On the other hand there were also less positive aspects of a system which relied to a great deal on a routinised, to some extent regimented pattern of care-giving in children's institutions. Before the economic crisis, when the institutions had better access to food and necessary inputs, there was some possibility of children spending overlong periods of time in these facilities, particularly the residential nurseries. This could have been problematic in terms of the potential for unbalanced child development which may occur if infants do not develop adequate psychological and physical bonds with the family, particularly the mother, at an early age. Subsequent to the economic crisis of the mid-1980s, as the children's institutions have come under stress, there is also concern that the pattern of care-giving, already fairly unindividuated, has become more impersonal as care-givers struggle to cope with extra burdens such as securing adequate food and basic goods (such as heating, basic medical supplies) for both themselves and the children for whom they are caring. It also seems likely that the cultural activities in which children used to participate within the institutions have been curtailed due to lack of play and musical equipment and due to the pressing survival concerns facing care-givers in the institutions.

4.4 Consequences of societal organisation

There have been many positive aspects of the organisation of society for the well-being of children

and women. Children have received access to care, education and cultural life and women were permitted certain freedom from domestic labour. The less positive aspects of large-scale institutionalisation, which have been accentuated by the economic crisis of the mid-1990s, include the risk of a lack of adequate psycho-social stimulation for the children and a weakening of family bonds. Conversely, whenever the children's institutions are less able to carry out basic care tasks - for instance the provision of food and basic health support - the extra burden falls on the mother who is the primary care-taker in DPRK society.

5. External political environment The external political and economic environment has a direct impact on the well-being of children

and women in the DPRK. Changing trade partnerships from the beginning of the 1990s have contributed to a search for new international relationships which can help provide needed inputs into the economy. International links are necessary for export markets, the provision of hard currency and, since the crisis of the mid-1990s, the direct provision of food and other emergency supplies. The overall political situation has affected the DPRK's ability to develop alternative markets and for instance to negotiate for loans from the international financial institutions such as the World Bank and the IMF. At the same time it has had an impact on the international humanitarian community's ability to fund its regular appeals for support. Thus far, the international political situation has facilitated the provision of humanitarian assistance. It cannot be guaranteed that the international political environment will continue to facilitate support for humanitarian assistance. On the other hand recent political developments in both the ROK and the United States in 1998 and 1999, which hold the promise of a less conflictual and more cooperative relationship with the DPRK, indicate that there are some possibilities that the international environment may be changing to permit the DPRK access to more long term assistance for reconstruction of the economy.

The DPRK continued its discussions with the World Bank and the IMF, an indication of its commitment to finding ways to become more integrated into the world political economy. Politically, the governments of the United States and the Republic of Korea are engaged in policies of positive engagement with the DPRK. In 1999, the President’s special representative for the DPRK, former Secretary of State for Defence William Perry produced a report that recommended the lifting of US sanctions and a policy of constructive engagement with the DPRK. Also in 1999, the ROK maintained and consolidated its ‘sunshine’ policy which involved the intensification of political, economic, and cultural links with the DPRK. In addition, the experience of China and Hong Kong with the success of a ‘one country-two systems’ approach seemed to offer a working example to the two Koreas of how two different political and social systems could successfully become integrated.

The DPRK maintained good relations with China while in 1999 it consolidated and improved relations with its neighbour, the Russian Federation. Signs of at least some rapprochement with Japan also were indicated as the DPRK and Japan resumed tentative dialogue in 1999, a positive step after the disruption to relationships in the aftermath of the 1998 satellite launch. The DPRK’s closest external relations with a major power remained with China which publicly reaffirmed its friendship with the DPRK in 1999.

6. Future scenarios

For planning purposes, it may be useful to think of three possible scenarios in the coming three years, within which programmes might need to be developed. Each of these scenarios would have different consequences in relationship to the survival, protection and development of children. The first and ‘optimistic’ scenario assumes improvement in the economy and a resumption of agricultural production. It assumes the government achieves its goal of cereal self-sufficiency by 2001 or soon thereafter. It would also assume a favourable external environment with foreign direct investment and the availability of hard currency and international loans for economic development. This scenario also assumes that investment in some of the public infrastructure becomes possible – at least enough to guarantee electricity supplies and to start to rehabilitate health, water and sanitation systems. Within this context, the government could afford to feed children and women with adequate food and to purchase adequate medical and health supplies. The government would consequently rely on the international community less for emergency supplies and more for capacity-building. The agencies could then more selectively target children in need of special protection measures for instance and work with the government in critical areas where supplies were still needed. The implications for children and women is that severe malnutrition could be dealt with in a more timely and efficacious manner with appropriate inputs and that the government could start to rebuild its preventative health system. Thus, children’s and women’s rights to survival could be better protected and the children’s rights to protection and development enhanced. The second and ‘pessimistic’ scenario assumes continued economic stagnation, possibly accompanied by more floods and/or drought. Agricultural rehabilitation is therefore delayed and food security remains unattainable. External political developments are again negative and as a result foreign investment remains limited, hard currency scarce and foreign loans unavailable. Public and social infrastructure investment is therefore only able to continue with the assistance of the international humanitarian community which, with its limited resources, would be insufficient to meet the various needs of the population, including the child population. Within this scenario, survival will remain an overwhelming priority. Medium to long tem rights to protection and development would be further threatened. A third and perhaps more ‘realistic’ scenario is that progress is made in some areas with recovery in agriculture and the general economic situation but at a slow rate. The work currently being done by international agencies continues along with limited foreign support from various donors for specific projects– for instance in the field of fertiliser and drug production. It is also likely that some parts of the country will see a quicker recuperation than others. This could be because they have better access to international aid or to governmental assistance. Transport and fuel problems for instance inevitably mean that services in outlying areas will be threatened in a time of national shortage – particularly in the winter. Where acute malnutrition remains, emergency assistance will still be necessary. At the same time, the international community could assist in laying the foundations for a development strategy which could be rapidly operationalised should conditions improve. Within this scenario, survival is still an issue, but strategies can also be implemented to encourage and support medium to long term reconstruction efforts in health, education, childcare and environmental services. Thus children’s rights to protection and development could also be supported.

7. Growing Partnerships The DPRK is reorienting its external relationships to reflect the changing political/economic environment of the late 1990s (see 5 above). Internally the government has worked closely with the international community to try to respond to the emergency needs of the population, particularly the most vulnerable - children, pregnant women and nursing mothers, the elderly and families without access to food or income (the latter through food for work schemes). The DPRK government works with UN agencies, national and multilateral governmental agencies and non-governmental organisations. 7.1 The UN agencies

Key UN agencies active in the DPRK are WFP, UNICEF, UNDP, WHO, FAO and UNFPA. WFP is by far the largest provider of food assistance. Between November 1995 and June 2000, it will have provided some $856 million dollars worth of food assistance to the DPRK. The July 1999 to June 2000 operation is designed to reach over 8 million beneficiaries - about a third of the population. UNICEF is the next largest operational agency in the DPRK with expenditure since 1995 of around $40. UNDP has been active in working with the government to produce plans for agricultural reconstruction and to the expansion of foreign trade, particularly in the north eastern free trade zone - the Rajin-Sonbong area. UNDP has worked with donor governments and the DPRK government to encourage foreign assistance in agricultural redevelopment through the provision of, for instance, heavy agricultural equipment and the rebuilding of fertiliser production facilities. Governmental agencies involved in the DPRK since the mid-1990s have included the food security unit of the European Commission and the European Community Humanitarian Office (ECHO), the Swiss Disaster Relief Unit and the Humanitarian Aid division of the Foreign Affairs Ministry of the Swiss government. 7.2 The non-governmental organisations The numbers of resident non-governmental organisations have changed. At the beginning of 1998 there were 5 resident NGOs, rising to eleven in mid-1998 and falling to 8 in September 1998. There have been many more non-resident NGOs who have visited the country since the mid-1990s and which are implementing programmes in the DPRK. Some of the non-resident NGOs – for example CARITAS – organise their inputs by way of the Food Liaison Unit (FALU) which works through WFP distribution channels. CARITAS has also channelled some assistance to health facilities through UNICEF, Save the Children work through the UNICEF establishment although they are discussing the setting up of their own office in the DPRK. The International Federation of the Red Cross and Red Crescent Societies are permanently based in the DPRK. Resident NGOs include CESVI, Concern Worldwide, Cap Anamur, German Agro Action, Campus fuer Christi Oxfam, Children’s Aid Direct, Action Contre la Faim. NGOs which have been resident and left the country include Medecins Sans Frontieres, Medecins du Monde and Help Aged International. NGOs discussing setting up a permanent presence include Handicap International. United States NGOs distribute food through the WFP channels and also have resident monitors in the DPRK organised in a Consortium of Private Voluntary Organisations ‘ the Consortium’ – which includes representatives of Mercy Corps International, World Vision and Amigos Internacionales, among others. 7.3 Developing cooperation Relationship between the government and the agencies developed through a process of dialogue and the activities of working together since 1995. There have been pressures on the agencies from donors to produce more information about the scale and scope of the crisis and the effectiveness of programmes. Cooperation in this area resulted in the 1998 joint government/EU/WFP/UNICEF nutrition survey and the government/UNICEF Multiple Indicator

Cluster Survey – both of which offered the partners useful information to help evaluate assistance programmes. International assistance initially concentrated on the provision of food aid and the supply of essential drugs, vaccines and essential medical equipment, chemicals for chlorination and supplies for the rehabilitation of water, environmental and sanitation facilities and basic goods such as warm clothing and blankets. Agencies have supported training for health providers, care-givers, management and supervisory staff of the ministries of health, city management, state planning and central bureau of statistics. Programmes of training have been carried out both in country and by study visits abroad. There is concern about the low priority given to support for capacity building and difficulty of evaluating the effectiveness of training programmes – again because of the problems associated with adequacy as well as collecting reliable feedback on programmes that have been carried out. 7.3 i Continuing difficulties

Both UN and other agencies continue to stress the importance of being able to professionally assess programmes through access to appropriate, relevant and accurate information. Some NGOs have been particularly dissatisfied and expressed the views that the constraints were such as to prevent them from properly fulfilling their missions. Many other NGOs, however, continue to develop cooperative relationships through continued negotiations with the government. There remains general concern, however, about the welfare of children and women in counties to which the international community does not have access.

UN agencies and NGOs coordinate their activities in the DPRK through the regular inter-agency meetings. Closer cooperation between UN agencies and the NGOs, however, particularly in terms of a more systematic sharing, analysing and dissemination of information is an area which could probably be of benefit to developing programmes to support children and women in the DPRK. 7.4 Consequences of international humanitarian partnership Although it is difficult to come to very precise conclusions due to the absence of an adequate information base, a large number of reports from various sources indicate that, as far as can be ascertained, food has been distributed to at least two thirds of the country. International assistance is not delivered to areas where the government does not permit monitoring. Reports indicate that assistance is reaching the most vulnerable. The developing international partnership of the last five years has therefore brought benefits in terms of the provision of basic supplies to many children and women who would otherwise have been facing starvation. There are still some difficulties in the relationship between the government and the humanitarian community, however, and these difficulties sometimes prevent the effective implementation of programmes to relieve suffering.

8. Framework of Analysis: the Rights of the Child The Situation Analysis is informed by the Child’s rights conceptual framework. The DPRK ratified the Convention of the Rights of the Child (CRC) in 1990 and developed a National Programme of Action to Implement the WSC goals. The DPRK government has submitted a first report on progress on implementation of the National Plan of Action to the UN Committee on the Rights of the Child and the second report is in progress. The DPRK government actively participates in intergovernmental ministerial meetings on the CRC and WSC goals.

Wellbeing of the Korean ChildWellbeing of the Korean Child

Adequate DietAdequate Diet Absence of diseaseAbsence of disease

Appropriate CareAppropriate Care Good Health, WES Good Health, WES Services Services

Availability, Management & Control of Org./Availability, Management & Control of Org./InstInst. Resources. Resources

Sound Economy / Social & Sound Economy / Social & PolPol. Org. OrgFavourableFavourable External Trade/Aid External Trade/Aid

Household FoodHousehold FoodSecuritySecurity

Survival, Growth, Development, ProtectionSurvival, Growth, Development, Protection

E d u c a t i o nE d u c a t i o n

Potential ResourcesPotential Resources

This conceptual framework illustrates how, in addition to the serious food shortages, problems in care practices and especially in the quality of health and water and sanitation services threatens the survival, growth and development of the children of the DPRK.

Survival, growth, development and protection of children is shown to depend on adequate nutritional intake and good health. In turn, these require sufficient food, adequate health care, and appropriate caring practices, such as exclusive breastfeeding, complementary feeding, home health care, psycho-social stimulation, and hygienic practices. To perform these activities the caregiver must have sufficient resources, adequate knowledge or expertise, and the will to put them into practice. Ultimately, all of the above depend on basic contributory factors such as the country’s potential resources and the ways in which they are mobilized and controlled through the nation’s social, economic and political organization and its relations with the external world. Relevant basic contributory factors, including both achievements and constraints, have been outlined in Section one of the Situation Analysis on the ‘national context’. The analysis in sections two and three evaluates more immediate and underlying factors that constitute challenges to and support for the well-being of the Korean child.

Section 2 The Policy Framework

1. Introduction The DPRK is committed to upholding and implementing the Rights of the Child as outlined in the CRC. Its Rights’ policies which include commitments to support the well-being of children and women can therefore be understood through the CRC framework of rights to survival, development and protection. Children’s rights are incorporated into various aspects of the DPRK’s laws, policies and state systems. Since the crisis of the mid-1990s, the focus has been on ensuring child survival, particularly for the infant and under 5s. The implementation of food and health assistance programmes and related activities since the mid-1990s, has meant that some shift in emphasis can now take place towards implementing the child’s rights to development and protection. Survival is still an issue for children and women, however, particularly those that for whatever reason are not receiving appropriate and adequate food, and health and social care. This section identifies the policy framework within which the DPRK seeks to implement child rights. It identifies relevant legislation, policies and areas of social provision. It identifies achievements as well as some of the challenges facing the DPRK in the attempts to secure child rights in the aftermath of the crisis of the 1990s.

2. The rights of the child The policy framework of the DPRK takes seriously the Rights of Children. A saying attributed to Kim Il Sung which is now well-known in both the DPRK and the international community is that the child is the ‘king of the country’. This saying encapsulates a policy commitment to support and care for children. DPRK policy of recognisng and prioritisng children has a long history. The ten-point programme of the association for the Restoration of the fatherland, which was issued on 5 May 1935 during the war against Japanese colonial rule, called for, among other things, the institution of free compulsory education and the prohibition of the employment of children. Since 1990, the DPRK government has adopted the CRC’s rights framework for developing policy in respect of children. The DPRK has developed a National Programme of Action (NPA) as a framework to achieve the goals of the World Children’s Summit.

2.1 CRC and the National Plan of Action

The DPRK has produced reports on the implementation of the CRC which identify achievements of the country in education, child health and nutrition. The first progress report on implementation of the CRC was submitted in February 1996, following on consultations with specialists from the Ministries of Foreign Affairs and Public Health, the State Education Commission and the Legislative Department of the standing committee of the Supreme People’s Assembly. This report identified gains in child rights during the period 1990-1994. Other organisations which contributed to this report included the Kim Il Sung Socialist youth League, the Korean Democratic Women’s Union, the Research institute of Law of the Academy of Social Sciences and other judicial bodies. The National Plan of Action includes a number of strategies in the fields of health (infrastructure, development, expansion of health research and management improvement), education (improvement of physical learning environment, strengthening educational content, improving teaching methodology and skills, integration of home-based and school learning, and research and development).

2.2 National Plan of Action (NPA) - objectives The objectives of the NPA for DPRK include the following: i) HEALTH

a) reduce infant mortality from 9.8 to 5 or less per 1,000 live births b) reduce the under-5 child mortality rate from 5.8 to 4 or less per 1000 live births c) reduce by half the mortality caused by diarrhoea and respiratory infections, the main

causes of child morbidity and mortality d) eliminate diphtheria, whooping cough, tetanus and poliomyelitis e) virtually eliminate congenital vascular disease and other congenital diseases and

malnutrition f) provide regular and thorough health check to all children, at least 30 times a year for each

child g) Emphasis to be given to preventive care, which is expected to occupy 70% of the above

schedule. ii) MATERNAL HEALTH AND FAMILY PLANNING h) voluntarily reduce the birth rate from 22.9 to 18 or less per 1,000 population i) register women before the third month of pregnancy and to provide ante-natal services

monthly thereafter j) deliver all pregnancies at a maternity hospital or delivery room by trained doctors or

midwives k) register all babies within 5-7 days after birth and to provide them with a thorough

medical examination l) reduce by half the rate of infection and death related to the major diseases of child-birth m) substantially reduce the mortality rate of women during childbirth and to reduce the

foetal death rate iii) NUTRITION n) virtually eliminate diseases of pregnant women caused by micronutrient deficiencies,

particularly of iron and iodine, and other forms of malnutrition o) virtually eliminate low birth weight (2.5 kgs. or less) p) provide milk products and other child foodstuffs to children of all ages according to their

needs q) increase the weight-for-age, height-for-age, and intellectual capacity of the child beyond

the current standards iv) EDUCATION

r) ensure that every child is educated in an appropriate school building through the

construction and repair of kindergartens and schools by increased state investment s) increase the availability of modern teaching aids and toys through the construction of

factories in the capital, provinces, cities and counties. At the same time, to produce and supply high quality educational materials suited to the age and psychological characteristics of children including musical instruments and tape recorders, as well as providing them with such audio-visual aids as VCRs, slides and overhead projectors

t) establish a supply of nutritious food appropriate to children’s ages and physical needs through the construction or modernization of food processing factories throughout the country

u) complete research on the content and methods of education in kindergartens and primary schools as early as possible in order to adapt the educational content by 1993 and, based

on that to public in large numbers textbooks and reference materials to help children develop their full potential

v) organize a wide range of teaching workshops, demonstration lessons, symposiums on teaching experiences, etc. On a nation-wide scale in accordance with the adapted content and methods of education, thus raising the level of education to a higher plane

w) increase State investment in improving the quality of education, in teacher-training institutions, and to provide sufficient modern teaching facilities and appropriate conditions for experiments and practice

x) maintain teacher in-service training centers in the capital and in every province, town and county to make such re-training a regular practice to improve teaching standards and to double the proportion of teacher qualified with first and second degrees

y) increase the scale and quality of training in teacher-training colleges z) upgrade the national audio-visual production center and promote the use of VCRs,

overhead projectors and slides in all schools and kindergartens by 1999

V) WATER, ENVIRONMENT AND SANITATION (from the World Declaration on the Survival, Protection and Development of Children and its associated Plan of Action)

i) provide universal access to safe drinking water ii) provide universal access to sanitary means of excreta disposal

3. Health

3.1 Introduction

This section sets out the structure of the health system, the staffing resources available to it, the

strengths and weaknesses of the system.

3.2 The health system The health system has universal coverage. The infrastructure is extensive, and organization of

services and staff continues to be solid. The health system has historically a strong preventative focus in its organisation of services. It has also nationwide provision for curative services. 3.2 i The national health care system: structure and functions

The health care structure is organised as follows.

Central Level

Provincial Paediatric Hospital

Provincial Hospital Provincial Maternity Hospital

Provincial Hospital

Factory Hospital County/City Hospital Ri hospitals

Farm clinics Ri clinics Polyclinics Farm clinics

The Ministry of Public Health (MoPH) manages the health care institutions and the state-run

nurseries. The MoPH is, further, divided into various departments, such as, surgical, medical education, medical research and public nurseries. Most of these departments are present at the provincial and county (or city) levels as well. There is one referral hospital in each province. At the county level, there is a county people’s hospital, a hygiene and anti-epidemic station, and pharmaceutical management stores. At the sub-

Red Cross Hospital University Hospital

county or ri level, there is either a people’s hospital or a polyclinic. There are, in total, 5341 ri and dong clinics and 908 ri and dong hospitals providing health care at the primary level.

Population and health institutions Province/City Population No. of

Counties

No. of District &

County Hospitals

No. of Dong or

Ri Hospitals

No. of Dong

Clinics

No. of Health staff

Pyongyang City

2,954,400 23 62 43 655 24,400

Kaesong City

360,400 4 13 51 53 2,332

Nampo City

787,200 6 24 24 112 4,061

South Pyongan 3,089,300 22 94 135 565 14,614

North Pyongan 2,627,100 24 97 107 666 12,242

Jagang

1,242,000 18 67 60 425 7,694

South Hwanghae

2,167,100 20 55 126 466 9,035

North Hwanghae

1,629,400 16 49 91 357 7,661

Kangwon

1,406,300 17 42 77 509 7,742

South Hamgyong

2,943,300 27 108 94 701 14,409

North Hamgyong

2,220,200 23 110 71 518 12,469

Ryanggang

687,200 12 56 29 314 4,529

22,114,000 213 777 908 5,341 121,188

Source: Ministry of Public Health, DPRK, 1999

The foundation of health care organisation is the section doctor scheme. The population is divided into sections, and a section doctor (also known as a family doctor) is responsible for the curative and preventive health care of 100-400 families, depending on the geographical location. At the ri level medical care is provided by the section doctors in the ri-clinic. In the morning patients visit the doctor in the clinics for treatment. In the afternoon the doctor makes house visits. During these rounds the doctor examines the patients and advises them about preventive health care. National surveys and health education are also carried out during these visits. The doctor keeps a medical record for each patient. Severely ill persons are referred to the county (city) hospital and used to be transported by the ri hospitals. In the ri-clinics a dentist and a midwife are also available. There are, however, no laboratory facilities at this level.

In the case of larger ris or when the ri is at some distance from the county hospital, the ri-clinics are normally equipped with some beds for in-patients. These ri-hospitals are responsible for a number of ri-clinics. Section doctors provide the only staffing for ri-hospitals. There is no specialist medical personnel at this level. Sometimes laboratory facilities are available in these hospitals.

Larger farms have their own farm clinics. Health services are available to all that are employed at the farm. Large factories have their own factory clinics and factory hospitals. The county department of public health and the respective factory management share the responsibilities of these health institutions. Residential children’s institutions and large nurseries have their own doctors. Smaller institutions are placed under the responsibility of a section doctor to take care of the health related problems of the inhabitants.

Section doctors are also appointed to the county/city hospitals. They perform the same tasks as ri-clinic section doctors for people living in the defined areas. The services of medical specialists, such as surgeon, obstetrician, ear-nose-throat specialist, ophthalmologist, dermatologist and pediatricians are also available in these hospitals. A county hospital usually has 100-150 beds. Each county hospital has an operating theatre and a laboratory. It is reported that laboratories used to be able to carry out 18 specific tests on blood, urine and stool. X-ray equipment is available in some county hospitals. A pharmacist is responsible for a pharmacy and looks after the supply of Korean medicines. Doctors can refer patients to the provincial hospital.

Provincial hospitals act as referral hospitals for county and city hospitals. The paediatric and the maternity departments are usually located in different buildings. Only medical specialists work in the provincial hospitals. It is reported that all specialists are available in these hospitals. The usual size of the hospital would be 750-1000 beds. Medical equipment such as X-ray machines, gastroscopes and ECG are available. From the provincial hospitals the patients can be referred to the university hospital or the maternity hospital in Pyongyang. At the central level, the Red Cross Hospital and the university hospitals are under the direct control of the central government. They are the referral hospitals for all the subordinate hospitals and clinics in the country.

3.3 Staffing and Training

There are 30 doctors, 18 nurses and 15 midwives per 10,000 inhabitants. Even the smallest ri-

clinic has a doctor, a nurse and a midwife. Section doctors are assigned to convey health messages and to identify health problems at an early stage. They conduct compulsory medical check-ups on adults annually and on schoolchildren bi-annually, and function as the sentinels for disease surveillance. Section doctors can be based in the ri and the county level. For instance section doctors at the county level are involved with immunisation campaigns. All doctors have six years of formal university training in medicine, and specialists undertake extensive post-graduate training. Nevertheless, doctors appear to have little familiarity with medicines and types of treatment which would be considered commonplace outside the DPRK. They do, however, have a sound knowledge of Korean traditional, often herbal, and preventive medicines.

3.4 Strengths and weaknesses of the health care system The DPRK has historically had an extensive and comprehensive health care system in both

curative and preventive care. The system is universal and free at the point of delivery. The DPRK’s achievements in the health field were remarkable. They included, among other things, reducing child and maternal mortality rates, increasing life expectancy and reducing the incidence of immunisable preventable diseases. The crisis of the mid 1990s, however, exacerbated the economic decline which had begun in the early 1990s resulting in grave setbacks for children and women’s health. Curative and preventive services were affected as the system ran out of essential drugs and medical equipment and staff were cut off from contemporary international developments in medical and health care practice. Staff also had to cope with extra, sometimes new tasks of which they had no previous experience including the diagnosis and treatment of severe child malnutrition and illness like tuberculosis. Signs of the challenges faced by the health service were high morbidity rates, and increasing infant, child and maternal mortality rates. Other signs of both crisis and the difficulties that preventive and curative services were having while coping with crisis were increased incidence of low birth weight, deteriorating maternal health, increases in acute respiratory and diaorrheal disease, a breakdown in local drug and vaccine production and deteriorating health infrastructure.

A major complaint in all hospitals is the lack of drugs. Field reports show that local production of drugs continues although at a minimal level, and in some areas may have ceased to function. Locally produced drugs are effective although the quality may be variable. Korean traditional medicines are still widely used. Donors are exploring the possibilities of importing raw materials for essential drugs, its production and packaging in DPRK. Lack of clean water and reliable supply of electricity and transport facility are the major hurdles for the pharmaceutical industry to overcome. The immediate critical issue is to maintain international assistance for the steady supply of essential drugs.

Health situation in DPRK based on 1993 census (unless otherwise indicated)

Population (millions) 21.2 Population under one (million) 0.046 Population under five (million) 2.07 % urbanized 62

Population growth rate 1.5 Total fertility rate (per woman) 2.1 Under 5 mortality rate (‘000) 31

(1996) * Infant mortality rate (‘000 live births) 23 Maternal mortality rate (per 100,000 live births) 41

(1996)* Hospital beds per 100,000 136 Doctors per 100,000 29.7 Crude birth rate 21 Crude death rate 9.3

(1998)** (Source: 1993 census. Information marked * is from State of the World’s Children, UNICEF, 1996. Information marked ** is from DPRK government 1998.

3.4 i Infant mortality

Evidence from the government/international community surveys and from field visits, however, indicates that nationwide incidences of diarrhoea and acute respiratory infections have increased significantly among all age groups in the last few years, these being the primary causes of infant and childhood morbidity and mortality. Malnutrition is believed to be a factor underlying most child deaths. The prevalence of vaccine-preventable disease such as tuberculosis, pertussis and neonatal tetanus is increasing while immunization coverage has decreased.

Infant mortality rate was estimated at 204 per 1,000 live births in 1945, dramatically falling to 15 per 1000 in 1996; it is reportedly increasing again. The under-five mortality rate stood at 30 per 1000 live births in 1990, but was reported to be 55/1000 in 1996. Average birth weight has reportedly dropped between 1994 and 1997.

3.4 ii Low birth weight

It is reported that at one of the provincial maternity hospitals, the average birth weight of the new-borns dropped from 2.9 kg in 1994 to 2.3 kg in 1997. The 1998 MICS indicates that just over 20 per cent of births are of babies of 2.5 kg and below. (See the pie-chart below).

Incidence of low birth weight

<2.5 kg >2.5 kg

Source: Multiple Indicator Cluster Survey, September 1998. Birth weight based on mothers’ recollection. Field observations and discussions with health providers and morbidity data indicate that the incidence of low birth weight is on the rise.

3.4 iii maternal health

The health of children relies heavily on the wellbeing of their mothers. Basic obstetric care is critical not only for mothers in preventing potential complications during pregnancy, delivery and providing the necessary care up to 45 days after childbirth, but it also gives the newborn his or her right to survival, development and protection.

All women in DPRK have access to prenatal care, and there is a comprehensive schedule for prenatal clinical visits. The 1998 MICS revealed that 99.9% of all married women who had children under 5, were ever registered for antenatal care. The total number of women who were eligible to be included in the study was 2957. Women who had children under 5 years numbered 1230 (41.6%) in the survey; and those who were ever registered for antenatal care when pregnant with the last child numbered 1229 (99.9%). Out of those who registered for antenatal care, 94.9% were registered in the first trimester of pregnancy. Only 1.3% of all deliveries were reported to have taken place at home (see Table below). Recent field reports are indicating, however, that due to the lack of drugs, equipment, heating, electricity and safe water supplies in clinics and hospitals, many women were choosing to have their babies at home.

The number of pregnant women seen at the time of the 1998 MICS was only 73. All pregnant women registered for antenatal care in the first trimester of pregnancy (see Table below). Furthermore, all pregnant women had seen trained health personnel during the time of pregnancy. The mean number of visits to the health personnel was 9.6 ± 5.9. The MICS findings indicate that pregnant women had regular access to section doctors during both prenatal and postnatal care. But evidently, along with the resulting data shown in the haemoglobin and weight at birth modules, adequate antenatal care has not been available, due to deteriorating health services, the limited familiarity of health providers with modern drugs and treatment methods, and delays in necessary referrals. As a result, good quality maternal health services during and immediately after childbirth is not always available. Referral is not widely practiced due to transportation constraints, deficient diagnosis of potential complications by health providers and poor quality of services in the referral facility itself.

In addition, despite an elaborate programme for antenatal visits, the policy of vaccinating the entire female population of reproductive age with Tetanus Toxoid (TT) every seventh year has not been strictly carried out in recent years. The vaccination coverage module shows only 26 women or 4.6% had two doses of TT and 3 women had three doses.

Maternal health services by type of settlement: DPRK 1998 (source: 1998 MICS)

Category Total Women ever registered for antenatal care 1229/1230 (99.9%) Time of pregnancy when registered First trimester 1162 (94.9%) Second trimester 61 (5%) Third trimester 1 (0.1%) Place of delivery Maternity hospital 330 (26.9%) County hospital 399 (32.5%) Ri hospital 263 (21.4%) Ri clinic 221 (18%) At home 15 (1.2%) Other 1 (0.1%)

(Source: DPRK government/UNICEF, MICS 1998) A specific problem affecting maternal health is the prevalence of anaemia as anaemic women

often fail to withstand even a minimum of blood loss associated with pregnancy. Anaemia and poor health in pregnancy are reported to be resulting in increased cases of miscarriage, stillbirths and low birth weight babies. Inadequate diet and/or inappropriate food intake is a cause of anaemia. Another possible cause is a

continued incidence of infection. Anaemia in pregnancy seems to be emerging as a public health concern, and is an associated cause of death.

Other contributing factors to poor maternal health include the high workload as mothers struggle to earn income, contribute to social reconstruction and at the same time seek to secure food and essential supplies for their children and families.

3.4 iv maternal mortality

Maternal mortality rate was estimated at 41 per 100,000 live births in 1996 (UNICEF, State of the World’s Children) although MoPH reported a figure of 105 per 100,000 live births in 1996. Most maternal deaths are perinatal, due to obstetric haemorrhage, infections and toxaemia. It is thought that maternal mortality is underreported. In 1998 UNICEF Pyongyang estimated the various causes of maternal death as set out in the table below. Infection, severe bleeding, unsafe abortion and eclampsia were identified as significant causes of maternal mortality

Estimated causes of maternal death in DPRK

* Other direct causes include: ectopic pregnancy, embolism, anaesthesia-related ** Indirect causes include anaemia, heart diseases. Vast majority of these causes are preventable through improved delivery care and emergency obstetric care (EOC). Source: UNICEF Pyongyang. Based on field observations, discussions with health providers and morbidity data.

Indirect causes**8%

Other direct causes *10%

Severe bleeding17%

Infection27%

Unsafe abortion 15%

Eclampsia13%

Obstructed labour10%

3.4 v disease

The health information reporting system for disease has weakened. However, the officially reported number of polio cases in 1995, 1996, 1997 and 1998 were 7, 6, 3 and 0 respectively. No cases of measles have been reported since the beginning of 1970s, which is also the case for diphtheria. For neonatal tetanus, the numbers reported were 3, 2, 0 and 6 respectively. It is probable that there is underreporting. Nationwide incidence of diarrhoea and acute respiratory infections among all age groups has increased significantly from 1994 - 1997. Among the 1,500 admissions from January to June 1997 in a paediatric ward of one provincial hospital, 750 cases were of diarrhoea and 350 of acute respiratory infections were reported. The 1998 MICS indicated high morbidity in diarrhoea and acute respiratory infections (ARI). Also for 1998, government reports indicated that mortality of children under 5 was 39.3 per thousand. Of this figure it was reported that 17.5 per thousand were due to diarrhoeal disease and 14.7 per thousand due to ARI. There also seems to be some indication that child mortality rates have plateaued because of the availability of antibiotics, oral rehydration and food along with some increase in knowledge and skill among carers. However there are no indications that morbidity of diarrhoea and acute respiratory infections is decreasing, presumably because of poor hygiene and difficult living conditions due to the economic problems besetting the country.

The number of cases of tuberculosis has increased substantially from zero in 1976 to 57 cases in 1996. These are largely under-reported, since a prevalence of 12,000 - 24,000 cases has been indicated. In 1999 the government and the international health agencies considered that tuberculosis had reached high proportions and were jointly conceiving a strategy to respond to this area of concern.

There were also concerns about the ability of the health service to maintain its previously impressive immunisation coverage against vaccine preventable diseases. The table below shows, for instance, that reported cases of neonatal tetanus jumped from none on 1997 to 6 on 1998. This figure confirms findings in the 1998 MICS survey that only a very low proportion of women had received the necessary second dose of tetanus toxoid vaccine (See Table in 3.4 v) below. Vaccine preventable diseases Official figures of the prevalence of vaccine preventable diseases are as follows:

Diseases Years 1995 1996 1997 1998 Polio 7 6 3 0 Measles 0 0 0 0 Neonatal Tetanus 3 2 0 6 Diphtheria 0 0 0 0 Japanese Encephalitis

No data No data No data No Data

Pertussis No data No data No data 32

(Source: DPRK government) 3.4. vi Immunisation

International reviews of the Immunization Programme in the DPRK were carried out in June 1992

and July 1999 with the participation of MoPH, WHO and UNICEF. Vaccines used to be produced locally either in the Pyongyang Vaccine Institute or at the Chongju Institute for BCG vaccines. These vaccines did not meet the WHO minimum standards. There was insufficient awareness about the necessity of storing vaccines appropriately, of effective cold chain management, and of broader issues of disease surveillance and contemporary developments in immunization. Local vaccine production, however, was severely curtailed in the mid-1990s because of damage caused by both natural disaster and economic crisis. Since

1996, both imported and locally produced vaccines have been in use for the EPI. WHO and UNICEF have been assisting the DPRK in its attempts to fulfill immunisation targets. Some vaccines continue to be produced locally and it is reported that with external assistance DPT vaccines could eventually meet WHO standards. The DPRK follows its own vaccination schedule, slightly different from the WHO recommended EPI schedule, but is gradually adopting the WHO recommended schedule. Vaccination coverage prior to 1994 was high, reportedly at 99 per cent. However, the rates dropped drastically since the national crises. Very major efforts are, however, being made to both increase local vaccine production and to recuperate levels of vaccination coverage. The DPRK has for instance implemented national Polio Immunisation days in 1997, 1998 and 1999. The table below indicates 1998 levels of vaccination coverage.

Vaccination coverage in DPRK, 1998

Vaccination Per cent

Tuberculosis (BCG) 63.9 DPT 3 37.4 Measles 34.4 Polio (OPV3) 76.5 Tetanus Toxoid (TT2) 4.6

(source: 1998 MICS survey) A reference laboratory to identify polio cases does not exist in the country. Information about

other laboratory facilities is also not available. It is likely that neonatal tetanus cases are under-reported. Despite the information obtained through the MICS and various other initiatives, the vaccination status of the country as a whole is unknown, and facilities for determining antibodies, if existing, are not likely to be functioning efficiently due to the country’s overall economic difficulties. A significant concern is that the precipitate factors for a major waterborne epidemic, such as poor sanitation, compromised water supplies and severe malnutrition, seem to be in place.

3.4 vii Functioning of health institutions The Ri clinics provide the community base for health services in the rural areas. Section doctors based at the Ri clinics deal with common health complaints as well as new areas such as severe malnutrition. Common health complaints include respiratory tract infections, diarrhoea, helmintic diseases (prevalence of worms), genito-urinary infections, skin diseases and arthritis. Field visits to the Ri clinics report that infrastructure, that is the buildings, remain intact but there is a general lack of services. Sanitation services and water supplies are compromised. Electricity is intermittent. It is a struggle to keep buildings clean and well maintained. Medical records are often not translated into effective clinical recording documents. Clinical documents and routine data on drug utilisation are not readily available to outside agencies. Medical equipment like stethoscopes and sphyganometers are old and in bad working conditions. Modern medicines are in short supply and antibiotics, such as tetracycline and ampicillin, are insufficient. Korean traditional medicines are widely used. A dentist is usually available but not dental equipment. Deliveries normally used to take place in the clinics and a midwife was available for obstetric services. Emergency cases used to be referred to the hospitals but transport shortages mean that this is not always feasible. There are an insufficient number of ambulances and fuel shortage mean that public transport is also often not available.

At the county hospital level, section doctors have similar duties as those in the ri-clinics. In addition, medical specialists to perform surgeries for conditions like Ileus, appendicitis, stomach perforation, traumas, ectopic pregnancy etc. Surgical skills seem to be sound although outdated techniques are used. It is difficult to maintain the cleanliness of operating theatres which are without means of temperature control. Instruments are either old or insufficient. County hospitals lack basic supplies including gloves, clean gowns, infusions and disinfectants. The autoclave is often rusty and as old as 30 years. Modern anesthetic equipment is unavailable and local or spinal anesthesia is very commonly used. Laboratory equipment often consists of an old microscope, lacking reagents and necessary equipment. The X-ray units are either old or in poor working condition, lacking spare parts and x-ray films.

In the provincial paediatric hospitals diseases such as pneumonia, dyspepsia, diarrhoea, malnutrition, meningitis and nephritis are diagnosed and treated. Many hospital buildings have windows without panes, insufficient water, intermittent electricity and no clean mattresses. There are too few beds with fewer blankets and sheets. At the provincial hospital level supplies are deficient in the provincial hospitals. Occupancy rates are low, particularly in the winter. Occupancy rates rise in the summer, mainly as a result of admissions in respect of diahhreal related disease. Provincial hospitals rely on the international community for drugs and medical supplies as local drug production is insufficient to meet needs.

There have also been concerns about a knowledge gap in health and care training, due to the isolation of the country from contemporary medical and health developments.

3.5 Summary

Because of its historic achievements in establishing a universal health service with a preventative as well as a curative bias, the DPRK is potentially well-placed to respond to the emergency situation of the late 1990s given appropriate assistance from the international community. The health system today, however, faces major challenges with shortages in drugs, medical equipment, and basic supplies. Current information on appropriate use of drugs, especially new antibiotics, is inadequate. Case management and diagnostic techniques need updating to reach international standards. A concern also is to ensure that DPRK medical and health personnel have access to contemporary developments in medical theory and practice. As the number of maternal and child health problems has increased, so too has the need to rationalize strategies and increase focus on the immediate and underlying causes of ill health among women and children. Preventive as well as curative services, with an integrated lifecycle approach and comprehensive care, need to be restored so that the foundations can be laid for a new generation of children and women who will be both healthy and free from any recurrent threat of malnutrition.

4. Nutrition 4.1 Introduction

This section sets out the structure of the way that child nutrition is addressed in the DPRK, evaluates the staffing resources available and analyses the strengths and weaknesses of the system. 4.2 The nutrition infrastructure: the distribution system and children’s institutions

Child nutrition is the responsibility of the Ministry of Public Health assisted by the Institute of Child Nutrition. At the provincial and county level, local departments of health take responsibility for nutritional support. Food supply formerly came through the Public Distribution System and, on the cooperative farms, from the farms themselves to their inhabitants. Workplaces and children’s institutions provided free meals. In cases of malnutrition, children could be referred to the provincial paediatric wards. Since the crisis of the 1990s, children continue to receive food in residential and non-residential institutions, but food and other nutritional support is now supplied through international assistance. 4.2 i Children’s institutions

International food aid to children is channeled through residential and non-residential children’s institutions (pre-school and schools). There is a very high rate of institutionalisation of child care in the DPRK. All children from aged three months have access to a nursery place. The over 30,000 nurseries are often located in the parent’s workplace. The total number of children under five in DPRK is 2,133,793 and is expected to increase during the coming years. In 1998, the government reported that the number of children attending nurseries (from three months to four years) is 993,000.

There are over 14000 kindergartens which take children from 5-6 years. There are just under 5000 primary schools for children from 7 to 10 years and 5000 secondary schools for children aged 10 to 16 years. Children living in remote areas have access to 1600 ‘Branch’ primary schools and 26 secondary ‘Branch’ schools. In addition, there are a number of institutions serving children in need of special protection. Baby homes (0-4 years), orphanages (5-6 years) and boarding schools (7-16 years) cater for children without parents and some destitute children, There are nine schools which cater for the mute and the deaf (9-18 years) and three which cater for blind children (9-18 years). The numbers of children enrolled in regular schooling are outlined in the next section of this report on education in 5.2. The numbers of children attending residential institutions are also set out below.

Children in residential institutions

Institutions Number of Institutions Age Group Number of Children Baby Homes 14 homes 0-5 years 3,000 children Orphanages 12 orphanages 5-6 years 1,995 children Boarding Schools 14 schools 7-16 years 4,200 children Schools for mute And deaf

9 schools 9-18 years 1,268 children

Schools for the Blind

3 schools 9-18 years 94 children

Total 52 institutions 0-16 years 10,557 children

(Source: DPRK government, 1998) 4.3 Staffing

Prior to the crisis of the 1990s, cases of malnutrition would have been dealt with in the health system, probably at the level of the provincial paediatric hospitals if the county did not have specialists available. After the natural calamities of the mid-1990s, child malnutrition was diagnosed and treated within the health system and, often, in the babyhomes, orphanages and boarding-schools.

4.4 The nutritional situation in the DPRK

The DPRK succeeded in achieving a standard of well-being for children which include the guaranteed right to food and care. Life expectancy grew from 38 years between 1936 and 1940 to 74 years in 1986. Life expectancy at 1997 is estimated at between 69 and 75 years. The most immediate manifestation of the crisis of the 1990s, however, has been food shortages, diseases and inadequate child care with documented extensive malnutrition among children.

A UNICEF report on nutrition from 1985 had stated that malnutrition in DPRK had been approximately five per cent among preschool children. It also indicated that statistics related to nutrition were difficult to obtain. Besides rickets, other micronutrient deficiencies were relatively unknown, even to health workers. There was no local name for night blindness, for example. Although anaemia was recognized, there were no statistics on its widespread prevalence. Rickets was estimated to be two per cent in cities and 0.1 per cent in rural areas. The average birth weight was in the range of 3.0 kg to 3.1 kg and it was seldom below 2.7 kg. The exception was for premature babies, the incidence of which was three per cent. Low birth weight (LBW) had a prevalence of 5.5 per cent among newborns. Breastfeeding was common although the same report stated that complementary foods were inadequate. 4.4 i The pre-crisis situation

A survey by the DPRK’s Institute of Child Nutrition (ICN) was conducted in 1988 in Kangwon province among 3,095 preschool children aged three to 71 months. The assessment was conducted by using the anthropometric indicators, such as weight-for-age, weight-for-height and height-for-age. In this study observations were made that the nutrition status of children between three and five months compared favourably with WHO reference standards. Growth started to falter from six months up to 17 months. Then it improved slightly or remained low through 71 months of age. Children aged six to 18 months were significantly below the WHO standard in all indicators. This confirmed that malnutrition started in the weaning period.

Moderate to severe malnutrition was perceived, in the survey, using weight-for-age indicator. The girl’s nutritional status was worse than boys, and children in mountainous areas were more vulnerable. The percentage of malnutrition in the various regions among boys and girls were as follows:

Malnutrition (in per cent)

Kangwon Province

REGIONS BOYS GIRLS Cities 1.8 3.0 Plains 1.2 4.2 Coasts 3.6 1.4 Mountains 4.5 6.0

Generally, mild malnutrition ranged between 17 to 37 per cent depending on the specific indicator

used. Seven per cent of the newborns in Kangwon weighed less than 2.5 kg. Children weighing 2.5-3.0 kg ranged from 53 to 65 per cent and only 27 to 40 per cent weighed 3.0 kg. These figures reflected the maternal nutrition and health status as well. Another study, conducted in Hyangsan in 1991, showed that more than 50 per cent of infants aged three to five months showed growth comparable with WHO standards. As in the earlier assessment, it was observed that growth started to falter from the age of six months and was the lowest among 12 to 17 months old children. This suggested the relation of malnutrition to inappropriate weaning and feeding practices. If situation of children of 18 to 36 months old did not improve, stunting would, undoubtedly, persist. The study also indicated a high prevalence of iodine deficiency among preschool children and their mothers. Micronutrient deficiency existed, therefore, prior to the crisis of the mid-1990s (see table below).

Micronutrient deficiencies among children prior to the crisis of the mid-1990s

Micronutrient Deficiency (in per cent)

Kangwon Province

Children Pregnant Women Iodine 13 - Vitamin C 12 - Vitamin A 15 - Vitamin D 10 - Iron 2 23

(Source: DPRK government, 1988)

Iodine Deficiency (in per cent)

Hyangsan county

Regions Pre-school Children Mothers Plains 11.1 – 18.8 11.2 Mountains 17.5 – 28.0 26.2

4.4. ii Changes in the mid-1990s Food shortages and deteriorating health services brought widespread child malnutrition to the DPRK in the late 1990s. Malnutrition was due to a complex interrelationship of causal factors. Children’s institutions were initially affected as food supplies diminished. International assistance targeted the children’s institutions with food and the government also set up residential homes for children whose parents could no longer care for them and provide food. International food aid and related assistance resulted in a diminution of malnourished children who regularly attended institutions but some concerns were expressed in 1999 about children falling outside the institutional ‘safety-net’.

Damage to agricultural production and reductions in successive harvests resulted in lack of food supply, which particularly affected children aged less than five years. Children in this age group are more vulnerable when food is scarce and of limited nutritional value because they need frequent meals of high nutritional content and high-energy value. Lack of food combined with a decline in the health situation, such as increased cases of diarrhoeal diseases and ARI, contributed to an increase in malnutrition among children. Children with repeated diaohhrea become weak and more vulnerable to other infectious diseases. Diarrhoea is common, especially in summer, and is caused by contaminated water or by the intake of inappropriate food (like raw food or unsafe weaning foods). It is also caused by bad hygienic practices, such as intake of unsafe drinking water and little use of soap, often due to lack of supply. ARI has not been treated effectively due to lack of drugs in the hospitals.

Other causes of malnutrition inappropriate weaning practices and lactation failure. Lactation failure was often attributed to mastitis (infection of the breast). Since there has been a severe shortage of antibiotics in the clinics and hospitals, appropriate treatment is limited. Poor feeding practices, absence of family support and lack of knowledge among institutional caregivers result in the increased incidence of malnutrition among growing children. Inadequate supply of supplementary food and poor health of mothers have also contributed to growth failure in children. Major causes of malnutrition also included lack of resources for the acquisition of food, absence of health care, impaired sanitation and compromised water supplies, and deficiency in hygiene practices.

Referrals of children for nutritional rehabilitation often were and still are delayed due to the incapacity of the caregivers to identify poor growth in a child or, simply, because the hospitalized child has not received adequate treatment. Food supplies to children’s institutions were initially deficient in quality and quantity. One consequence was that parents were asked to give contributions in cash or in kind (mainly rice). Another consequence of food shortages was poor attendance in many nurseries. Field observations in 1998 indicated that attendance was greater at nurseries that had access to food than at those where food has

not been available. In 1997 and 1998 some field reports indicated that the situation in cooperative or state farm nurseries was better than in the city nurseries. Further reports in 1999 indicate that although food supplies are improving for the nurseries with international assistance, attendance remains low (compared to enrollment figures).

Baby homes, orphanages and boarding-schools were set up in their current form in 1997. These were based on institutions which may have once catered primarily for orphans or other groups of children. However, they seem to have been expanded and utilised as emergency nutritional rehabilitation centres and care institutions for families who for one reason or another could no longer care for their children. Reasons include illness of the mother and destitution. In DPRK, adoption or fostering has been a tradition and is supported by law. The extended family, friends or the cooperative used to care for orphans and sick children. With the deterioration in the food situation, it is proven more difficult to feed an extra child. Thus a child that became moderately or severely malnourished was referred to a baby home or residential children’s institution. In 1999, severely and moderately malnourished children are still being treated at these institutions although there remain concerns about the quality of care.

In 1999, concerns were also expressed that some severely malnourished children were not attending nurseries, nor in the residential children’s homes and not receiving appropriate emergency treatment. Given that the Ri level health institutions do not have the means to treat these children, there is real concern that these children are at a high risk of dying. Some NGOs are working on a more localised basis in 1999. It might be appropriate therefore for the international community and the government to develop a strategy whereby food, medical assistance and support in care and treatment could be organised at the Ri level. 4.4 iii A malnourished child population

The 1998 governmental/international community nutritional survey of children aged between six months and seven years old indicates that of the 3 million children in this age group, around two-thirds are suffering from some form of malnourishment. Approximately 420,000 have low weight for height (wasting) with 64,000 in a severe condition – indicating that these children are suffering from acute malnutrition (see graph below). Approximately 2 million children aged between six months and seven years have low height for age (stunting) with about 1.3 million in a severe condition of low height for age (see graph below). These stunting figures are an indication of chronic malnutrition. The percentage of children suffering from wasting and stunting at the same time and therefore in immediate need of support was 9.5 per cent – around 30,000. Given that the nutritional survey was based on access to 61 per cent of the country and covered children up to seven years of age only, and given the probable difficulties in remote areas which do not have international access, it is possible that these figures provide an underestimation of the scale of malnutrition.

Boys 23.1 45.6 63.7 74.6 80.1 76.4 67.3

Girls 8.2 51.1 60.2 75.6 75 73.4 63.4

All 14.5 48.5 62.2 75.1 77.5 74.8 62.3

6-12 months 12-24 months 24-36 months 36-48 months 48-60 months 60-84 months TOTAL

Boys 19.1 36.5 25.3 16.3 14.6 11.7 17.9

Girls 16.5 25.8 14.2 9.2 3.1 4.2 10.8

All 17.6 30.9 20.5 13.4 8.9 7.8 15.6

6- 12 months 12-24 months 24-36 months 36-48 months 48-60 months 60-84 months TOTAL

Nutrition status of children under 7 years of age

Stunting among children under 7 years of age

Source: Nutrition Survey, September Wasting among children under 7 years of age

Source: Nutrition Survey, September 1998. Wasting (weight/height< -2Z) is the most sensitive indicator of the current situation, indicating the rate of acute malnutrition. Very high wasting in the 12-36 months age group, especially among boys, indicates a serious food and health problem.

(Source: Nutrition Survey, September 1998. Survey conducted by UNICEF,WFP and EU in partnership with the Government of DPRK.)

4.4 iv scale of malnutrition and the necessity for universal intervention

The scale of the problem of both acute and chronic malnutrition calls for a comprehensive response. Low weight for height (wasting) did not seem to have declined between 1997 and 1998 despite the international food distribution to children and pregnant and nursing women. There is also no evidence of a decrease between 1998 and 1999. Reports indicate that the scale of acute malnutrition is diminishing among children who attend nurseries but, by contrast, there appears to be a problem of continuing severe malnutrition evidenced in children who are not regularly attending nurseries. Although it is difficulty to draw meaningful comparisons from the very different situations of other countries, the fact that severe wasting in Indonesia, the Philippines and Vietnam is less than half the DPRK rate gives some indication of the severity of the problem. In 1998 the stunting rate of children aged 6 to 84 months was about 62 per cent. Although there are no figures for 1999. the continued national food shortage, micro-nutrient deficiencies, the high prevalence of wasting and a high recorded morbidity including diarrhea and acute respiratory infections would make an increase in the stunting rate expected. Again, these rates are higher than those in other countries. The high prevalence of both wasting and stunting indicates that nearly all children in the DPRK are being affected by the complex causation of malnutrition in the country. Any strategies designed to cope with malnutrition therefore need to be directed at the entire child population. Visible wasting needs to be treated as a medical emergency otherwise there is a risk that the child will die. Given the higher prevalence of wasting in the under two child population and the increase in stunting, the entire under two child population should be targeted for adequate complementary food assistance and micronutrient supplementation. In terms of the broader causes of malnutrition in the DPRK, disease prevention and management and micronutrient supplements are required along with improvements to the sufficiency and adequacy of food supplies. It is imperative, therefore, that further assessment take place in the nutrition status of children in order to be able to plan interventions more effectively, to assess their impact, and to be able to chart changes in need. It should also be noted that because mothers are malnourished and/or underweight, this contributes, among other things, to the high incidence of low birth weight and, reportedly, to difficulties in breast-feeding. 4.4 v Micronutritient deficiency

The 1998 MICS found evidence of that 31.7 per cent of children under seven years of age and 34.7 per cent of pregnant women suffered from anaemia (see graph below). It is likely that the prevalence of anaemia is even higher in infants given their relatively higher energy requirements.

Prevalence of Anaemia

Source: Multiple Indicator Cluster Survey, 1998 This graph illustrates how in addition to PEM, micronutrient deficiencies are equally serious

among children and pregnant women.

children U7 pregnant women

HB<11g/dl HB<7 g/dl

High levels of goitre have also been recorded, indicating iodine deficiency. Iodine is required for the

synthesis of thyroid hormones, which in turn are needed for the regulation of metabolic activities of all cells throughout the life cycle. They are also required to ensure normal growth and development. Iodine Deficiency Disorder (IDD) is the most prevalent cause of preventable mental retardation in the world. WHO/UNICEF criteria are that a public health problem exists if prevalence is above 5 in the school age population (7-16 years). The MICS (of children aged only between 6 months and 84 months) showed that 4.2 per cent of children had visible goitre with 7.8 per cent of children in the age range between 60 and 84 months having visible goitre. Some provinces are more affected than others. A 1998 report by the DPRK State Planning Commission found that iodine deficiency is endemic in the mountainous regions, where prevalence of goitre is reported to be at 26 per cent. The report found a 10 per cent incidence of goitre in children aged 4-6 years in 1998 ranging though to a nearly 20 per cent rate in children aged 11 to 16 years (see table below).

The rate of IDD prevalence in various provinces Provinces

Prevalence of IDD (in per cent)

Chagang 26 Ryanggang 20.9 Gangwon 16.9 North Hamgyong 15 South Hamgyong 15 North Pyongan 10.7 North Hwanghae 6.9 South Hwanghae 4.4

There is also some concern about non-visible iodine deficiency which may not be easily diagnosed and therefore treated in a timely manner.

Sea salt production is much reduced due to floods. Floods and tidal waves between 1995 and 1997 destroyed salt pans and depressed the production of salt. In addition, although the country is surrounded by sea, 80 per cent of the land is mountainous. Koreans use Soya sauce and kimchi as a source of salt. To prevent iodine deficiency, however, iodised salt needs to be introduced into the diet. Seaweed is also used as a dietary supplement for iodine. It is reported that pregnant and lactating women in maternity hospitals used to be given seaweed. Awareness about the importance of iodine to the body and the intake of food containing iodine is not generally high although the government has embarked on a number of research projects in relation to iodine deficiency, for example to encourage the use of soya sauce instead of salt. Soya sauce however would also need to be fortified with iodine. Taking into account the dismal quality of children’s diet in the late 1990s, it can also be assumed that deficiencies in zinc and Vitamin A are common. Vitamin A deficiency contributes to poor sight and also the weakening of a child’s immune system – thus allowing further vulnerability to infection. Rickets cases are frequently observed which indicates Vitamin D deficiency. 4.4 vi Breast feeding and complementary feeding in the DPRK

Breast feeding is common practice in the DPRK although there are some concerns about the exclusivity of breast-feeding. Weaning practices have probably been deficient for some time due to lack of appropriate foods. The food shortages of the 1990s had a deleterious impact on the ability of mothers to breast feed and also resulted in a worsening of the situation in regard to the supply of appropriate and adequate complementary or weaning foods for infants. Delayed introduction of semi-solid food is a major cause of child malnutrition as from about six months breast milk cannot provide all the required nutrients for the growing infant. From this age, semi-solids (complementary food) are needed in addition to breast milk.

The 1988 survey by the Institute of Child Nutrition (ICN) of Kangwon province indicated that although breastfeeding was universal, 10 per cent of mothers in the cities stopped breastfeeding in the first six months, 67 per cent terminated between seven to 12 months and only 23 per cent continued for more than a year. But in the rural areas two to four per cent terminated breastfeeding during the first six months and over 50 per cent continued after one year. There was also an inverse relationship between education and length of breastfeeding similar to that which has been observed in other countries.

Breastfeeding was extensively practiced for a period of eight months to one year, usually starting 12 to 24 hours after delivery. The child was breastfed every three hours in the hospital. Breastfeeding was estimated at 95 per cent in the first month after delivery and 52 per cent after six months. There are no statistics indicating if this is exclusive breastfeeding or not. In a few cases of lactation failure, fresh goat or cow milk or milk powder was used. In nurseries breastfeeding usually lasted for eight months to one year, even when mothers went to work. The Government legislated to the affect that a mother has the right to leave work to breastfeed her child every two hours, during the first year after delivery. In the second year the mother could breastfeed her child in the morning, when she left the child in the nursery, during lunch hour and, in the afternoon, when she collected the child. During busy farming season infants were brought to the field for breast-feeding. There is some data which indicates that 23 per cent of children used to be bottle fed at six months. During illness, mothers generally stopped breastfeeding and gave soup or sweet and salt mixture. The MICS confirmed a high incidence of breast-feeding but it remain unclear whether the legislation on breast-feeding time is rigorously enforced

In 1998, some DPRK health workers were reporting a decline in breastfeeding. The reasons given were various - sometimes the mothers cannot produce enough milk due to lack of food or the mothers are advised by family members not to breastfeed in order to save energy. Another reason given for the decline in breastfeeding is the prevalence of breast infection (mastitis) and lack of proper medicines for treatment.

Although Pyongyang maternity hospital has now been awarded UNICEF ‘baby-friendly’ status because of its support of breast-feeding, practices in some hospitals do not encourage good breastfeeding behaviour. Usually, the mothers do not start breastfeeding until after 12 to 24 hours of the delivery. The belief that colostrum is dangerous is quite common and the child is given sugared water in the initial days after birth. Hospital staff, family members and friends sometimes provide mothers information on appropriate ways of breastfeeding and ways to stimulate milk production. Access to modern information on the significance of breastfeeding is not always available. In urban areas, substitutes like bottle-milk sometimes considered to be better options than breastmilk.

The 1998 MICS reported fairly high levels of exclusive breastfeeding – with 85 per cent exclusively breastfed until six months. There are, however, some concerns about the accuracy of this picture. In many other countries, survey results have shown relatively high responses to exclusive breast-feeding questions. Yet often the mother may not perceive water for instance as affecting the exclusivity of breastfeeding. In a situation where water supplies and sanitation is compromised, the giving of water to babies may be a relevant factor in assessing how and why infants become malnourished. Further information should be sought in this area.

Complementary food was introduced at five or six months of age. It mainly consisted of rice gruel, initially thin in consistency and gradually thick and concentrated. Weaning foods called Um and Juk used to be composed mainly of boiled rice, eggs, fish and vegetable powder and were low in energy density to meet the needs of a growing infant. The quality of weaning food was therefore not assured and very probably lacked adequate nutrients. At eight months a child was given mashed beans, flaked fish, meat, eggs and soft vegetables. Fruits are, generally, not given to children. After one year the child was given adult food such as rice, fish, soup and chicken. In big nurseries, in Pyongyang, children were given infant formulas or grits. Formula food consisted of rice or corn, beans, oil, yeast, salt and vitamin supplements. In most nurseries children were given local food such as rice, potatoes, fish, carrots and oil. This was often prepared by nursery staff, mainly from fruits and vegetables. The food processing method is drying and grinding. There have been no tests on the nutrient content of these foods. Canned processed food was only available in the cities. 4.4 vii Stress and the care-takers

As the previous system of nutritional support broke down, institutional child-carers have struggled to deliver care to children without having the necessary inputs into the system to support them. In addition, child carers were having to cope with new problems – of child malnutrition – without expertise in this area.

The management of High Energy Milk (HEM) supplies, for instance, needs some care and attention. Over-diluted HEM does not assist in the therapeutic feeding for which it is designed. Conversely, HEM which is not diluted enough, can kill a severely malnourished child. It takes time and care to feed a child with HEM and as caretakers have become overburdened with trying to maintain basic care standards, there have been reports that HEM is not always properly used. In addition. there is evidence that HEM has been stored past its expiry date, probably because authorities have been concerned about running out of supplies. Such HEM then becomes useless for the purposes or which it is designed. These practices may be changing as the community authorities experience continuity of support from international agencies.

As medical supplies ran out and child health deteriorated, carers were often having to then deal with foreign drugs (if they could obtain them) – again of which they had no experience. Isolation from contemporary developments in care practice also meant that management of care was sometimes not as effective as it might be. For instance, diaohhrea management tended to reflect now discredited practices (of withholding food and fluids from the child) simply because the carer was not aware of how medical knowledge had changed. In addition, the poor economic situation meant that no funds were available for play equipment and so the psycho-social development of the child was affected. Reports also indicate that the number of care-givers was often insufficient to deal with the new problems faced by large numbers of children. Although a minimum number of care givers per child is fixed by law, the numbers of staff are invariably insufficient to deal with the extra burdens caused by the economic crisis. Finally, care givers themselves are suffering stress as the overall economic situation of the country affects their own families – including particularly the lack of access to food. Food shortages, stress and over-work might also have contributed to an observed listlessness and apathy among some care workers. 4.4 viii Food distribution and supply

International food aid was initially targeted at children aged 6 months to 6 years. There are increasing concerns about the nutritional status of 7 to 12 year olds and older children. WFP aims to try to provide food to prevent severe malnutrition and to support nutritional rehabilitation of those who are already severely malnourished. UNICEF continues to support therapeutic feeding programmes and works to provide health, water and sanitation and some educational support in order to provide a comprehensive support in the battle against malnutrition. WFP and UNICEF are also working together with the government to provide a dedicated blended food factory. In the medium to long term, UNDP is working with the government to resuscitate domestic agricultural production – introducing double cropping initiatives, providing supplies and technical assistance and encouraging crop diversification. Reports indicate that the DPRK will continue to face a substantial food shortfall in 2000. 4.5 Summary

Although it is likely that a number of workplace linked educational institutions will have shut down due as factories have closed or rundown their output, the children’s institutions continue to provide the base of a viable infrastructure for food distribution. There are, however, some limitations to the system as a basis for ensuring children are receiving adequate nutritional support. Firstly the baby homes, orphanages and boarding schools that have become used as specialist institutions for nutritional rehabilitation for children in the provinces are not providing adequate care. Nutritional rehabilitation is not an appropriate function for these children’s homes. Staff are untrained and overwhelmed by other basic care tasks and children are deprived of parental and family support in these institutions.

Secondly, although the quality of care in children’s institutions appears to be variable, they continue to provide the infrastructure for food distribution from the international community. In 1999, there is increasing concern that some children are not reaching institutions for nutritional support – particularly in the outlying areas. Reports from field workers indicate that some severely malnourished children are not receiving assistance and are therefore likely to die.

Finally, the 1998 nutrition survey recorded high rates of both low weight for height (wasting) and low height for age (stunting) in the DPRK. These figures give cause for great concern particularly because of the irreversible nature of stunting which in 1998 was recorded at 62 per cent of children aged 6 to 84 months. The country has a great challenge in terms of curative care for those children severely and acutely malnourished. Perhaps the greater and more long-term challenge is that of prevention to try to ensure that future generations do not face the same problems as today’s children and women.

Unprotected source 0.2%Hand pump in dwelling

8%Tube well or borehole

Public tap 1%

Piped water 75%

5. Water, environment and sanitation (WES) 5.1 Introduction

This section sets out the structure of the water and sanitation services, evaluates the staffing resources available and analyses the strengths and weaknesses of the system. 5.2 The water, environment and sanitation infrastructure

The Ministry of City Management (MoCM) has responsibility for the water supply and sewage system. The Ministry of Public Health (MoPH) has responsibility for public health. Relevant departments in the MoPH include the Department of Therapy and Prevention, the State Hygiene Control Board, the Department of Health Education and the Department of Guidance of Nurseries. 5.2 i Water supply a) Coverage

According to 1997 reports from government officials, there were 30,000 water works in the DPR Korea, and all except 1,000 were in working condition. In urban and rural communities 70 per cent of the population have access to piped water supply. Those who do not receive piped water, collect their drinking water from village pumps, household wells, springs or adjacent rivers. The piped water system is, probably, less developed in the ris. Very often, houses and institutions have their own water sources. On the basis of this, it can be calculated that almost 14 million people have access to piped water whereas, at least, six million people rely on alternative water sources, mainly bore-holes and wells with hand-pumps. No information is available on the distribution of surface water versus groundwater among the population. b) Water sources

The public water supply system is a surface water based system, particularly in urban areas. Less focus has been laid on the possibilities of groundwater sources since the water bearing layers (aquifers) are thin and, therefore, prone to over-abstraction. Raw water is drawn from larger rivers. Insufficient sewerage system may have led to the discharge of faecal pollution into these rivers. Pollution from agriculture, industries and other human activities has also contributed to the threat that communities confront when they are depended on these sources. Groundwater sources are reported to be more common in the rural area and relatively safer for drinking as contamination of these sources is remote. Even without disinfectant, deep groundwater sources can be reasonably safe drinking water resources. However, shallow dug wells can also easily become contaminated if they are dug near to latrines or a sewage system. The 1998 MICS determined the main sources of drinking water as set out in the pie chart below.

Main sources of drinking water

Source: Multiple Indicator Cluster Survey, 1998.

c) Water works

An assessment conducted by Oxfam in October 1997 concluded that, of the works inspected, technically, they were in a good condition. The pumps were well maintained and coagulation and filtration processes were conducted normally. Two main problems were highlighted. Firstly, no disinfection procedures were being carried out. Secondly, regular power failure led to insufficient piped water for all needs. The assessment was based on a very limited number of water works mainly situated in the urban districts, and the findings can not be extrapolated to the country, as a whole.

In Nampo city, for instance, which was heavily affected by the tidal waves in August 1997, excessive damage to the public water supply system has occurred, especially to the distribution system. As a consequence, about 1,200 wells have been dug after the tidal waves. Although maintenance of pumps and worn out equipment have not been raised as a problem by the authorities, rapid deterioration of water pumps and their pumping capacity has been reported.

d) Water distribution system

The conditions of water mains remain unidentified because the details about their exact location were lost during the Korean War. Hence, the location of the oldest and, presumably, less fit pipelines, in many places, are still not known. The water supply authorities fear leakage along the pipelines. Due to lack of equipment necessary for checking water mains as well as leaking spots, the extent of the problem has not been identified. As most of the water works are only working intermittently, low pressure in the mains for most of the day leads to cross contamination from waste water in sewerage pipes especially when laid nearby. Ministry of City Management (MoCM) has confirmed that water mains and sewers are laid in the same trench.

e) Water quantity

Official data suggests a previous consumption of 300-350 litres of water per person per day, which seems highly improbable. A more likely estimate is the consumption of 150 litres per person per day. Irregular water supply has reduced the consumption level considerably. In some houses the piped water supply is insufficient to meet all needs. People have been observed washing clothes and taking bath in the rivers. But water being carried to houses has not been observed indicative of sufficient supply of water for drinking and cooking. In 1997, many institutions were reported to receive tap water in the morning and evening for two or three hours only. The fact that many institutions have internal water storage tanks near taps suggests that they have been facing the problem of irregular water supply for some time. An associated problem is the necessity to carry water up several flights of stairs in apartment buildings, many of which lack elevators or which may function irregularly. Women carry a disproportionate share of the extra work burden in this area. The 1998 MICS indicated that water was available on a daily basis as indicated in the table below.

Mean hours water available per day

Source: Multiple Indicator Cluster Survey, 1998. Field observations, discussions with health providers and morbidity data suggest that availability of safe drinking water (both in terms of quality and quantity) continues to deteriorate.

f) Water quality

No systematic data on the microbiological quality of water is available. The results of Oxfam UK’s water quality tests in their targeted areas show over 95% of pre-chlorinated urban water supplies represent a health risk from faecal contamination of which 50% are heavily contaminated, according to WHO guidelines. A limited assessment of well water quality, undertaken by Oxfam UK during September/October 1998, revealed that 100% of the wells fell into ‘intermediate to very high risk’ faecal contamination categories. Although data from UNICEF’s 1998 Multiple Indicator Cluster Survey (MICS) showed universal access to water supply and sanitation facilities, the same data also indicated high diarrhoea morbidity (20.3%) among children under 5 years. This can largely be attributed to drinking contaminated and untreated water, use of inadequate sanitation facilities and unhygienic practices.

The deterioration of water quality and the content of organic pollution in areas affected by floods and tidal waves are on the increase. Apart from the environmental degradation, the increased content of organic matters in water sources is the result of the discharge of untreated or insufficiently treated effluence from sewerage plants. Organic pollution enhances the demand of coagulants for flocculation and chlorine for disinfection. In 1997, apparently because of the unavailability of chlorine for some time, the MoPH recommended that drinking water should be boiled for 30 minutes. To what extent this recommendation was followed is unknown. Fuel is short and people do not always follow such advice. In rural areas, the microbiological contamination of ground water, from wells and springs, is less. This is particularly so when such sources are located away from latrines and sewage. g) Water treatment

Aluminium sulphate as coagulant is used to carry out flocculation and filtration of water. Although the capacity to produce aluminium sulphate has been affected by floods, alternative methods have helped to overcome any shortage. Coagulants are added to the water in proportion to its turbidity. The procedure is standardized for the country as a whole, and does not take into account local variations in raw water quality. Potentially, this may be an inefficient way of using scarce resources. The Government has raised lack of coagulants as a matter of concern. The existing method for treatment or purification is based on using Sodium Hypochlorite as disinfectant, and most water works are equipped accordingly. The main problem is that chlorine has been unavailable since early 1996. Although necessary equipment is available at the treatment plants, they may be in a state of disuse without mechanical stirrers, drive belts or damaged dosing pipes. UNICEF and Oxfam are providing calcium hypochlorite as a partial response to some of these problems.

9.110.3

24 24 24

Hours/Day

Piped water Public tap Tube well orborehole

Hand pump indwelling

Unprotected source

h) Water quality control

Two agencies of the Government monitor the quality of the water. They are the Ministry of City Management (MoCM – the department for water supply) and the Ministry of Public Health. The MoCM has a comprehensive testing scheme to carry out tests every second hour at the water treatment reservoir and several times a day at selected places along the distribution system, such as, nurseries, kindergartens and factories. Physical, chemical and microbiological tests are reported to be routinely carried out. It is somewhat unclear what microbiological analyses are carried out and to what extent they are appropriate to measure faecal contamination.

The method adopted at Namgang water works in the outskirts of Pyongyang (as observed during a 1997 field visit) used inappropriate incubation temperature and medium for the identification of relevant micro-organisms. The MoCM is establishing a central laboratory for water and environmental sanitation. Lack of basic equipment and reagents disrupt the effort to become operational. The situation is similar in the laboratories at provincial, city and county levels. The MoPH has hygiene and anti-epidemic laboratories based at provincial and county levels. These laboratories also perform surveillance of water quality. Almost 22 chemical, physical and microbiological parameters for water quality are reported to be tested in these laboratories, but the exact type of analysis is currently unknown. I) Supply of essential chemicals for water treatment

The Ministry of Chemical production (MoCP) is responsible for the production and supply of water treatment chemicals. Although floods have disrupted the chemical plants and there have been difficulties in the supply of raw materials, production has been maintained in a limited way. Aluminium sulphate, which is used as coagulant in the treatment process, is reported to be available in small quantities. There is, however, some concern about the required quantity and the domestic production capacity. In Pyongyang, it is reported that the treatment plants are using copper sulphate. The annual consumption of sodium hypochlorite is reported to be approximately 10,000 MT. In comparison, the total domestic production of chlorine was estimated in 1997 at 4,000 MT per year. UNICEF and OXFAM UK are providing one quarter of these supplies. How much of this chlorine is distributed to the public water supply is not known. Reports indicate that chlorine produced domestically is being used for other purposes.

The demand of chlorine for the nation, as a whole, is roughly 15 MT per day of high quality chlorine powder when the estimated consumption of piped water is 150 litres per person per day and the requirement of calcium hypochlorite to purify one cubic metres of water is five grams (that is, 65-70 per cent of active chlorine). The quality of the locally produced chlorine powder is probably low. Furthermore, there is a demand for chlorine to disinfect drinking water extracted from dug wells and springs. It is estimated that about US $2-3 million is required to rehabilitate the chemical plants to resume total production of chlorine in the existing plants. In 1999, MoCM officials reported that production of chlorine had resumed on a small-scale.

J) Safe drinking water for children’s institutions

Many public health officials have acknowledged the need for intervention to reduce the incidence of diarrhoeal diseases among children. Exposure to contaminated water is a major risk factor for the occurrence of diarrhoea in children’s institutions. The advice to boil drinking water for 30 minutes may account for the absence of a major outbreak of diarrhoea. However, some concern is evident as the current recommendation could be compromised due to limited resources of fuel and wood. Therefore, it is desirable to promote chlorination of drinking water rather than boiling as a method of disinfection, both to protect children’s health and save fuel and firewood, and thereby prevent deforestation. 5.2 ii Sanitation

General environment contamination by excreta, solid and liquid waste often leads to the proliferation of disease-bearing agents and insects. Vulnerability to these agents results from lack of supplies and equipment and inappropriate health practices. Unfortunately, environmental sanitation is considered only after the need for food, water and health have been addressed. Efforts to integrate

Flush to sewage system Flush to septic tank Pour flush latrine Dug latrine No facilities

environmental sanitation issues during the initial assessment are crucial. Moreover, preventive sanitation measures are intrinsic to the provision of safe food, water and health. a) sewage system

DPRK had a modern, water based sewerage system in urban areas and, thus, was depended on sufficient and continuous supply of water and electricity to pump sewerage away where it does not flow by gravity. Irregular water supply due to constant power cuts means that water needs to be poured into toilets to flush them. Together with interrupted pumping capacity. These circumstances can ultimately, lead to blockage of the sewerage system. The authorities also report that they have problems with soil entering the sewers causing blockage of the pipelines and overflow of the sewage. According to the 1998 MICS, 99.8 per cent of households had access to sanitary facilities for human excreta disposal in the dwelling or within a convenient distance from the dwelling. Again according to the 1998 MICS, 80 per cent of rural and urban households use dug latrines (see Table below). The excreta from latrines is used for agricultural purposes.

Type of toilet facility

Source: Multiple Indicator Cluster Survey, 1998. b) Treatment of sewage Sewage is treated in open septic tanks. Treatment consists of sedimentation, bio-chemical digestion and drying in open lagoons. Sludge from the lagoons is re-cycled as fertilizer on agricultural land. At present, the sewerage system does not have the necessary capacity to ensure safe disposal of human waste. The effluence from sewage plants used to be disinfected using sodium hypochlorite, which is unavailable currently. In the future, the Government intends to carry out disinfection by irradiation or ozone. b) Drainage of surface water Drainage of surface water in the provincial cities is primarily based upon open lined and unlined drainage channels, which are kept very clean and free of rubbish. Thus, water stagnation is not a problem. Flies are reported to be a huge problem during the summer months. The current situation in rural areas, where latrines are common, is not known but is presumed to be bad.

5.2 iii Hygiene

Reports indicate that most of the children’s institutions visited have appropriate and clean facilities for washing and water storage to cover periods when tap water is unavailable. Institutions connected to the public supply system frequently experience disruption of tap water supply during most of the day. In rural areas, institutions commonly have their own wells or water pumps. Sometimes water for all purposes, other than cooking, is collected from nearby rivers. There is a shortage of soap. The use of locally produced liquid soap, which is conceived to be less effective, is quite common.. 5.3 Staffing

There is an extensive system of post 16 years old education in the DPRK. Technical staff have access to specialised schools and university level colleges. They also have access to a system of part time adult education which is based in the workplace. Staff responsible for water and sanitation facilities have shown great skill in improvisation.

5.4 Strengths and weaknesses of the WES systems

The DPRK built an impressive agricultural, industrial, residential and public infrastructure. All this infrastructure required a secure water supply. Before the economic decline and the recent natural disasters, most people, whether they lived in cities or agricultural co-operatives, had access to safe tap water and, at least in the cities, flush toilets. In 1998, the MICS indicated that 75% of households had a piped water supply and 78% of households had access to a toilet (see graph above).

The breakdown of the public water system in highly populated urban areas could lead to large-scale outbreaks of water-related diseases if the situation continues to deteriorate. Interruption in electrical power and the lack of spare parts for the aged motors and pumps in water supply stations have resulted in the interruption of household services. In addition, the lack of calcium hypochlorite, due to problems with in-country production, resulted in many treatment stations pumping water directly to consumers without chlorination, exposing many people to great risk. This is being mitigated, to some extent, by encouraging the population to boil their water, although it is recognised that fuel is scarce.

The capacity of laboratories in anti-epidemic and water treatment stations to monitor high risk water supplies and to address the problem in a timely manner, has been seriously undermined due to lack of equipment, reagents and technical capacity. Thus untreated and treated water can flow to consumers without having been adequately test for their characteristics and chlorine contents. 5.4 i Water

Water quality remains a major concern of the government. Damage caused by floods and tidal

waves to public water works, disruption of the production of essential chemicals for water treatment, limited maintenance capacity and irregular power supply are all important factors which have contributed to the breakdown of services.

The problem of irregular water supply has existed for many years and people have adapted to it. To what extent domestic and personal hygiene is compromised remains unclear. There is, however, some indication that water borne diseases are a public health concern. Storage of water adds new risks if strict hygienic rules are neglected. Once contamination occurs it can lead to water or food borne infections for an extended period. Insufficient supply of soap for personal hygiene, cleaning and laundry is an additional problem, especially in the children’s institutions.

Continued international assistance to ensure accessibility to uncontaminated water and food, as well as to maintain good personal and domestic hygiene is essential. To avoid the detrimental effect that diarrhoea could have on children already suffering from poor nutrition, attention should be on the water supply. This would include assistance in the provision of water disinfectant until the domestic production is resumed, rehabilitation of chlorine processing plants, monitoring and management of the production and

supply of drinking water, rehabilitation and maintenance of existing supply systems and development of alternative sources.

5.4 ii Environment and sanitation

Irregular water supplies have demanded changes from flush toilets to sewage systems into pour flush latrines. Public latrines have been made available in areas where the sewage systems are broken down. Conditions of latrines are not always acceptable and many are of the open drain type. The most urgent need in urban areas is the restoration of sewer mains and the sewerage treatment plants. In rural areas, satisfactory sanitary conditions could be achieved if education is coordinated with the construction and rehabilitation of latrines. According to the 1978 MICS, 79.7 per cent of the population are using dug latrines. These are unsanitary facilities and can contribute to sanitation related diseases.

The DPR Korea suffers from a chronic shortage of chemical fertilizers. Consequently, excreta from latrines, sludge and sewage from sewerage plants, manure and compost are important sources of organic nutrients in agriculture and horticulture. Improper treatment of these residues may represent a threat to human health when used as fertilizers. Similar hazards arise when contaminated water is used for irrigation.

Poor sanitary conditions are also ideal breeding grounds for flies, a big problem during the summer season due to the floods. Although flies have been identified as vectors for pathogens, their significance in the transmission of diarrhoeal diseases is not clearly established. Poor environmental sanitation may also provide the mosquitoes with appropriate breeding sites and, thereby, increase the spread of mosquito borne diseases. Addressing the current sanitation problem is necessary to diminish the people’s exposure to water borne, food borne and vector borne diseases. 5.4 iii disease and diarrhoea

Comprehensive health statistics or surveillance data on infectious diseases are unavailable. The incidence of water and sanitation related diseases as well as their causes are largely unknown. The 1998 MICS indicated high diarrhoeal morbidity (20.3 per cent) among children under five years old. A majority of these are likely attributable to poor water and sanitation. Field reports have revealed that diarrhoea is perceived as a major cause of ill health among children, even during the winter season. Diarrhoea continues to jeopardize children’s well being and survival, in conjunction with malnutrition, impaired child’s environment, inadequate personal hygiene, and crowded settings - as steadily more children are admitted into institutional care.

The most worrying epidemiological risk factor is that, in many places, lack of water treatment capacity coincides with an increased contamination of surface water reservoirs and ingress of polluted soil and groundwater. Discharge of untreated or partially treated effluents from sewerage plants, leaking sewer water mains and runoff from agricultural catchment areas expose people to pathogens propagated by water route. Basically, both primary and secondary barriers against the spread of water borne diseases are violated and, very likely, the drinking water is often contaminated. The use of surface water is characteristic of the most densely populated areas in the DPRK. As a result, the possibility of a water-borne epidemic and its effect on the people is very worrying. A single source of pollution in an urban water supply could such an epidemic in an entire urban area.

Morbid conditions among children under 5 years of age

Source: Multiple Indicator Cluster Survey, 1998. Mothers of children were asked to recall the occurrence of few symptoms during the last two weeks preceding the survey. Recent data on under 5 mortality suggests that diarrhoea, respiratory tract infections and meningitis are on the increase and responsible for over 80 per cent of the deaths in this age group. 5.4 iv Hygiene

The awareness of hygiene practices appears to be good although it is difficult to maintain proper hygiene practices in the absence of soap and regular access to water. To what extent hygiene messages have been adapted to the current situation with water shortage and a possible increased exposure to contamination, is not clear. In children’s institutions, the potential risk of infection due to an unreliable water supply and improper sanitation facilities is considerable. Water-borne infections are the main contributor to many children suffering from diarrhoea, skin and eyes diseases. The lack of soap makes good hygiene practices difficult to maintain. 5.5 Summary

The DPRK achieved nationwide water and sanitation infrastructural coverage. The nation’s capacity to maintain safe and secure water and sanitation services was severely damaged in the 1990s. The government and people responded to crisis with remarkable skill and through improvisation managed to keep services going. The obverse side of the achievements shown in improvisation is that a certain amount of deskilling appears to have taken place. The economic crisis has meant that it has been necessary to continue to operate obsolete equipment without access to appropriate spare parts. This has also meant that certain necessary procedures have not been able to be maintained. Deskilling may then have taken place as technical workers no longer were able to maintain good practice due to economic constraints. This would indicate the need for capacity building as well as capital inputs in any programme of international assistance in this sector.

In terms of children’s nutrition and health status, improvements cannot be expected without securing a safe water supply and adequate environmental sanitation and hygiene. Particularly at risk are children, but women bear the bulk of the labour associated with inadequate services including compromised water supplies and inadequate sanitation infrastructure. Extra physical and psychological

20.3 20.517.2 15.2

Diarrhoea Runny nose Cough Fever

burdens are placed on women who, as the primary care-takers, must try to cope with family food and health problems at the same time as dealing with, inaccessibility to safe water. Women suffer the hardships of water collection and the indignities of inadequate sanitation. In children’s institutions, the special needs of sick children means that care providers carry an extra workload. These special needs may also exhaust scarce medical and nutritional resources

6. Education 6.1 Introduction

This section sets out the structure of the education system, evaluates the staffing resources available and analyses the strengths and weaknesses of the system. 6.2 The education infrastructure: institutions and curriculum

In the DPRK education comes under the portfolio of the State Education Commission (SEC), divided into the Ministry of Higher Education (MHE), the Ministry of General Education (MGE) and the General Bureau for Supplies and Teaching Materials (GB). A Minister, who is also the head of MHE, is the Director of the SEC. Another minister of a lower rank heads the MGE while the GB is under the General Director. Each ministry and the GB comprise of several other departments. At the Provincial level a similar structure of Higher Education, General Education and General Bureau is established. The counties have a single Education Section. The Department of International Cooperation and Education, which is within the SEC, coordinates students living abroad. Koreans study in China, Cuba and Thailand.

The numbers and types of pre-school and school educational facilities are set out in the table below. The State Education Commission is responsible for all the residential children’s institutions except the baby homes which are administered by the Ministry of Public Health.

Education Facilities

Type of School No. of Institutions No. of Children attending

Age Group

Kindergarten 14,167 756,000 5-6 years Primary school 4,886 1,536,000 7-10 years Senior Middle school 4,772 2,140,000 11-16 years Primary Branch schools 1,600 656,000 6-10 years Secondary Branch schools (for first and second year)

26 1,800 10-16 years

TOTAL 23,851 5,089,800 4-16 years (Source: DPRK government, 1998 and 1999)

6.2 i Structure and Curriculum

The school year starts on 1 April and ends on 31 March. It is divided into two semesters. The first semester begins on 1 April and ends on 31 July. It is followed by a term break from 1 to 31 August. The second semester starts on 1 September until 31 March with a winter break of 20 days in December. At the end of each semester an examination is conducted to evaluate the performance level.

Kindergartens have a simple curriculum. The children are taught counting, Korean language, the lives of the Arts and Crafts, Music and Moral Science. The primary schools teach the same subjects as in kindergarten, with particular attention given to the Korean language and Mathematics. History and Nature are included as additional subjects. Physical Training is also introduced at this level.

Curriculum content at the secondary level is more comprehensive. It includes Korean literature, foreign language, History, Geography, Mathematics, Science (Physics, Chemistry and Biology), Basics of Electronics, Arts, Crafts, Moral Science, Biographies of late president Kim Il Sung and Marshal Kim Jong Il, Leader, Music and Physical Training. An emphasis is placed on literature and language, mathematics and science. Male students learn how to operate basic machine tools. Female students learn to sew and cook. Special classes are conducted for girl students to orient them to womanhood.

6.2 ii Children in need of special protection measures

In 1998, around 10,500 children were reported to be in three institutions for children in need of special protection measures. Residential institutions house handicapped children, orphans and those without parental or family support. The number of children in need of special protection has increased during the last three to four years as parents and families have become unable to feed and care for children because of the country’s economic difficulties.

After the war in 1954, war orphans had been cared for in institutional settings but there is some evidence that these institutions fell into disuse and disrepair as these children grew up and left these residential homes. This was partly because adoption was also encouraged by the state so that children would not have to enter residential care. The difficulties of the recent years have decreased the number of families able to cope with feeding and caring for an extra child and this is one reason for the rapid growth in residential homes for orphaned and destitute children since 1997. Orphans represent, however, only a small proportion of these institutionalised children.

Nine Boarding Schools for deaf and mute children and three institutions for blind children, with a relatively easier curriculum than the normal schools, are established. Vocational training, such as tailoring, shoemaking, video and TV repair, is provided in these institutions to children of eight to 18 years of age for effective social integration. Physically and mentally disabled children are usually integrated into mainstream schools with special care by teachers and fellow students.

The numbers of children in institutions designed for children in need of special protection are given in the table below.

Children in need of special protection measures – institutions (Source: DPRK government, 1998)

Institutions Number of Institutions Age Group Number of Children Baby Homes 14 homes 0-4 years 3,000 children * Orphanages 12 orphanages 5 and 6 years 1,995 children * Boarding Schools 14 schools 7-16 years 4,200 children * Schools for mute And deaf

9 schools 9-18 years 1,268 children

3 schools 9-18 years 94 children

Total 52 institutions 0-16 years 10,557 children • numbers constantly change for a number of reasons. New children are admitted. Some

children are adopted and some return home after nutritional support. Some are referred to hospitals and some die.

The locations of the specialist schools foe mute and deaf, and blind children are given below. Also given are the locations of babyhomes, orphanages and boarding schools which are situated throughout the country. Approximate numbers of resident children (in 1998) are given below.

Schools for mute and deaf children Province Name of the School South Pyongan Songchon County school North Pyongan Unjen County School Dongrim County School Chagang Sijung County School South Hwanghae Bongchon County School North Hwanghae Bongsan County School Kangwon Wonsan City School South Hamgyong Hamhung City School North Hamgyong Sambong county School

(Source DPRK government 1998)

Province Name of the School South Pyongan Daedong County School South Hwanghae Bongchon County School South Hamhung Hamhung City School

(Source DPRK government 1998)

Baby Homes (under 0-4 years)

Province/City

Name of Baby Home

Number of children*

Pyongyang Pyongyang City Baby Home

Ryanggang Hyesan Baby Home

Nampo Nampo Baby Home

S. Hamgyong

Hamhung bay Home

Kangwon Wonsan Baby Home

S. Pyongan Pyongsong Baby home

N. Pyongan Sinuiju Baby Home

N. Pyongan Ryongchon Baby Home

S. Hwanghae

Haeju Baby Home 185

N. Hwanghae

Sariwon Baby Home

N. Hamgyong

Chongjin Baby Home

Kaesong Kaesong City Baby Home

Jagang Huichon Baby Home

* Not a constant figure

Orphanages (5 and 6 years)

Province/City Name of Orphanage Number of children*

Ryanggang Hyesan Orphanage 100 Nampo Nampo Orphanage 117 S.Hamgyong Hamhung

Orphanage 300

Kangwon Wonsan Orphanage 200 N.Pyongan Sinjiju Orphanage 255 S.Hwanghae Haeju Orphanage 160 N.Hwanghae Sariwon Orphanage 250 N.Hamgyong Chongjin

Orphanage 260

Kaesong Kaesong City Orphanage

* not a constant figure

Boarding Schools (7-16 years)

Province/City Name of Boarding

School Number of children*

Pyongyang Mirim Boarding School

Ryanggang Hysean Boarding School

Nampo Nampo Boarding School

N.Hamgyong Kilju Boarding School 520 S.Hamgyong Hamhung Boarding

School 320

Kangwon Wonsan Boarding School

N.Pyongan Dongrim Boarding School

S.Hwanghae Haeju Boarding School

S..Hwanghae Jaeryong Boarding School

N.Hwanghae Pongsan Boarding School

Kaesong Kaesong Boarding School

6.3 Staffing and training

Teaching is a respected profession in the DPRK. The late president Kim Il Sung stated in his “Thesis on Socialist Education” that “Teachers are directly in charge of education work. In our society they are career revolutionaries who bring up the younger generation as heirs to the revolution.”

According to DPRK government figures, the 1999 pupil-teacher ratio was 1:23. One hundred per cent of kindergarten teachers were women. Overall, 57 per cent of teachers are female. In 1998 the official figures on numbers of teachers for the different institutions were as set out in the table below:

Institution No. of Teachers Kindergarten 37,000 Primary 69,000 Secondary 112,000

Teachers are trained in teacher training colleges, universities of education and through

postgraduate and doctoral training. Kindergarten and primary school teachers are trained at the 14 Teacher Training Colleges, one centrally located in Pyongyang, one each in Nampo and Kaesong and 11 in the provinces. These courses last three years. Senior middle school teachers are taught over a five year period at the 19 universities of education. Teachers in universities and colleges are trained at the postgraduate and doctoral level over three to four years.

On completion of three to five years of service every teacher reportedly undergoes an upgrading training of six months duration in one of the 226 Teachers’ Refresher Training Centres. Refresher Training Centres are located at the central level in Pyongyang, with one in each province and 214 at the county levels. All teachers receive training from their respective regional centres or centrally in Pyongyang. Teachers also attend a re-training course twice a year for 10-14 days during their summer and winter vacations. There is little information as to the quality of teacher-training, in respect of the content of the syllabus, the types of teaching methodologies used and the methods of learning assessment promoted. 6.4 Strengths and weaknesses of the educational system

The DPRK made remarkable gains in the area of education. The nation has a reported near universal adult literacy. Education is universal and compulsory in the Democratic People’s Republic of Korea. Children are educated to become responsible for the future of the nation. They receive free and mandatory schooling for their future role as nation-builders.

Top-most priority was granted to education in the formative years of the nation. Illiteracy was eradicated after compulsory primary education was introduced in 1956 and secondary education in 1958. Since 1959, all education has been made free of cost providing accessibility at the grassroots level. The 11-year cycle of learning process (one year in the kindergarten, four in the primary school and six years at the secondary level) was made obligatory in 1972. This included all children between five and 16 years of age.

Besides the mainstream schools, numerous other nurseries, weekly and short-period kindergartens have been established to facilitate working mothers. All schools are located within a distance of two kilometres from the home to ensure total enrolment and regular attendance. Children received free meals, clothes and medical care besides free education in the schools. Those who are endowed with exceptional talents, or with physical impediments were provided with specialist support.

The first year of the kindergarten is optional but a net enrolment of 95 per cent has been recorded. Attendance is generally assessed through the daily roll call. The State Education Commission reports that close to 100 per cent of children are enrolled every year in the country’s 27,391 primary and secondary schools. However, there is no clear indication about the daily attendance rate. Nearly 100 per cent of all enrolled children reportedly graduate from the primary to the secondary level every year. Dropout rate is reportedly zero. Most children participate in extra-curricular activities that are meant to contribute to the

overall development of the child. These activities are encouraged by the authorities. Gifted children are given special support at the various ‘Children’s Palaces’ throughout the country as they are considered the future stars of the country as artists, dancers, painters, musicians and singers.

Students in remote mountainous regions and on islands along the coast receive support in order to enable them to attain the same level as urban students. The branch schools, with less than 80 to 90 students, were established under the supervision and responsibility of a Head Master of a nearby primary or secondary school. Multi-grade teaching was abolished in branch schools in 1994. These schools receive an equal share of educational materials, clothes, equipment and teacher’s in-service training.

For a period, it seemed that the education system in the DPR Korea was still formidable in terms of quality and outreach, and it appeared that the economic difficulties and the natural disasters had little impact. The problems have, however, taken their toll. A government report stated that 1997 was the first time since the Korean War that students began their new academic year without printed textbooks. The 1998 MICS reports almost 100 per cent school enrollment. However, there is some concern that attendance has been affected by the economic crisis. Until the natural calamities took their toll, children of school age were never now seen loitering on the streets during school hours, especially in cities like Pyongyang. This is still in 1999 not a major problem but there is still some visible non-attendance at school. 6.4. i Coping with the crisis The educational system and the achievements of the DPRK have come under considerable stress because of general economic decline in the 1990s and because of the severe damage caused by the natural calamities of the mid-1990s. The DPRK government reports that in 1995 4120 kindergartens and 2290 primary and secondary schools were washed away by the floods, destroyed or submerged by water. The government reports that large amounts of educational equipment including 3,462,000 textbooks were destroyed. The government also reported that in 1996 403 schools were destroyed after the floods of that year.

Children and teachers are attempting to learn and teach in the context where all face food shortages and many are suffering from some degree of malnutrition. The physical infrastructure of school buildings is rundown and buildings lack access to a regular safe water supply, adequate sanitation and constant adequate heating in the winter. There is little funding available for the purchase of teaching equipment, including textbooks, basic teaching materials such as paper and writing tools, and play equipment. In this context, the quality of learning outcomes must be affected. Field reports indicate that children are receiving less than adequate psycho-social stimulation. This appears to be partly because of a lack of material support but also because dealing with the general situation of food and nutrition deprivation has become, understandably, the first priority for students and teachers. Educational goals will be inevitably retarded unless large-scale interventions are made in support of the creation of a safe, secure, warm, healthy and educationally stimulating environment for all children. This is clearly a major task which requires substantial international support. There is some concern that because of the country’s isolation, teachers have not had access to contemporary developments in teaching and learning. Given the lack of precise information available, it is difficult to make a detailed assessment as to how the quality of education in the DPRK has been affected. It seems reasonable to suppose, however, that many of the gains previously made in the DPRK, for instance the achievement of universal literacy, are being threatened by the current crisis. 6.4 ii Orphanages and boarding-schools

Orphanages and boarding schools have been regularly visited by various international resident and non-resident humanitarian agencies. All report over-crowding, lack of adequate heating and supplies and deficiencies in care and education practices. Cooperation takes place between the various agencies but no far no common information base has been established and common interventions planned. Given the relative lack of information on the nutritional, health and development status on children aged over 5 years old compared to the under 5s, it might be a useful step for UNICEF to organise a common data base on these institutions. Such a data base could be updated regularly on the basis of a common report form, a system of shared analysis and dissemination of such analysis between the partners. On this base effective and well-planned common interventions could be planned.

6.5 Summary

The DPRK made great achievements in the spread of universal literacy and with the implementation of the eleven year system of free compulsory kindergarten, primary and secondary education. Those achievements have come under threat from the country’s general economic crisis and the impact of the natural disasters. Of particular concern is the institutionalisation in residential homes of children without parental support.

Section 3 Living in crisis: the child in the DPRK 1. Introduction: 1.1 child survival, growth, development, protection and participation in the DPRK

From the end of war in 1953 until the late 1980s and the onset of economic decline the life of children in the DPRK had seen major improvements. The country’s economy grew and the government invested in industrial and agricultural production and also in health, education and public infrastructure and services. Cooperative farms and the Public Distribution System guaranteed every child and adult access to basic supplies, including food but also clothing. Food, clothing and housing was thus provided by the state, as was access to free education and health care. The child’s right to survival and growth was therefore guaranteed by the state.

The child’s development rights were also provided through the state – in education and care which was made available to children from the age of three months through the widespread provision of nurseries and kindergartens. The development of a system of eleven years compulsory education, combined with an extensive tertiary sector also mean that child development rights could be sustained through state provision. It is somewhat difficult to make an assessment of how vulnerable children were protected from harm as very little is known about the care of children with disabilities, children in remote areas, and children at risk because of parental absence prior to the 1990s. There is some evidence that war orphans were given some priority within social service provision, partly by way of encouraging adoption. The education service also established branch schools (see Section 2, 6.4) to provide accessible education for children in the remote areas although there is some indication that these were never very well resourced.

Participation rights were and continue to be fostered as part of the state’s philosophy which argues that children are important as the future builders of the nation. All children from the age of seven are members of the Children’s organisation and from the age of 13, all children are members of the Kim Il Sung Socialist Youth League. These are not state or party organisations although they are linked to the party. These children’s and youth organisations are based within the local community with activities centring around the school. Activities range from painting, learning to play musical instruments, dance, singing, sport and also participation in social mobilisations. These mobilisations include keeping local streets tidy, helping families without resources to assisting in planting and harvesting. In the 1990s, particularly since the widespread economic damage caused by the natural calamities of the mid-1990s, children’s rights to survival, development and protection are sharply threatened. There is some evidence that participation rights for some children have been maintained as the youth organisations have been involved in helping to respond to the economic difficulties facing the country. It is not clear as to the extent of involvement of children in the running of these organisations although, as the whole country is by law run according to the principles of democratic centralism, it is likely that the leadership plays a predominant role under the guidance of the KWP. Irrespective of the extent to which children participate in decision-making, such a development is by no means universal, as some children and women face threats to survival to such an extent as to preclude their ability to exercise participation rights.

1.1. i service provision: foundations, challenges and possibilities a) foundations

Sections 1 and 2 of this report document the extensive public service infrastructure created since the inception of the state in 1948. The DPRK invested heavily in social provision in education, health, housing and guaranteed the provision of basic supplies to all its people. Many countries which were newly independent in the post second world war period did not prioritise the provision of social services. The DPRK both prioritised social provision and to a certain extent, as far as can be ascertained, achieved more or less universal provision of services. Apart from the objective of providing a decent quality of life for its people in general, DPRK social provision was explicitly aimed to improve the status of women and to lessen the burden of domestic work on women. Children and women also benefited from the social provision available with decreases in infant mortality and maternal mortality rates, increases in life

expectancy and the achievement of universal literacy. DPRK achievements were recognised worldwide when north Korean citizens won gold medals in Olympic and other international sports as well as receiving international honours for cultural achievements, for instance in circus and choreography. Another positive affect of the collective organisation of DPRK society was the promotion of social cohesion.

Much of this impressive extension of public service provision was achieved through both paid work activity and through collective, non-paid work by the people mobilised through their various social organisations. The Worker’s Party of Korea, the Korean Democratic Women’s Union, the general federation of Trade Unions of Korea, the Kim Il Sung Socialist Youth League, the militias and various other organisations participated in these activities. These organisations and others continue to participate in public service activities. In health, for instance local Red Cross organisations, continue to work extensively throughout the country. Another feature of the public service provision was that it was often achieved with limited inputs and technology – with the population as a whole demonstrating a tremendous ability to improvise with minimal resources so as to improve and maintain basic services.

b) Challenges

The economic difficulties facing the country in the 1990s have severely challenged the previously established social infrastructure which had provided the framework from within which child rights had been implemented. Secondly, the economic difficulties of the country also called into question some established social practices in terms of their potential negative affect on child rights.

Firstly, the public infrastructure could no longer guarantee supplies of basic goods including food such as to guarantee the right of child survival. The capacity to improvise had its negative affects as the population was pushed to respond to the crisis with the expenditure of more physical energy and fewer material inputs. Further improvisation on top of already sometimes makeshift maintenance increased vulnerability of the economic infrastructure to major shocks like floods, tidal waves or drought.

Secondly, as farm production failed and the PDS could no longer deliver food and basic goods nationwide, state facilities such as schools and workplaces became bereft of supplies and could no longer provide food, income and adequate care. The collective provision through which the state had organised its activities was threatened but at the same time there was not much of a familial or individual safety net upon which to fall back. In the main, individuals and families had been discouraged from providing for their own singular needs, as opposed to collective needs, so there was not much of a foundation for individual coping strategies once the crisis struck. Individuals in the rural areas had been permitted to engage in very small-scale production, but this limited production could not provide for basic food or income needs of the population as a whole.

Women, as the primary caretakers had to take responsibility for meeting the basic needs of the family. Women therefore had to find ways to continue working to maintain income, sometimes as the main breadwinner, to find food and clean water and to look after sick children. All these tasks had to be done without access to transport. Health services were without supplies and shops without goods. There is little evidence of the sorts of psychological stress as well as physical stress this places on women. Some evidence of stress in the society may be reflected in the visible incidence of smoking and drinking among men although it is hard to quantify these factors.

There have also been some negative affects for children and women of the collectivisation of social provision. The widespread institutionalisation of children from a very early age – as early as three months – may have in some cases damaged the psychosocial bonds necessary for development between mother and child. The children’s institutions in turn, while providing a positive environment in some respects for the development of creativity through encouraging art, music and sport – also, more negatively, based their operations on a high level of regimentation. A high level of regimentation can lead to what are the now very well understood side affects of ‘institutionalisation’ – lack of initiative, inability to cope outside familiar routines, difficulties in establishing inter-personal relationships, psychological estrangement from the family, etc.

The lack of access to developments in changing social care and support practices because of the isolation of the country has contributed to the maintenance of regimented institutional systems which, while once widespread universally, are equally universally today considered potentially damaging to child development. Regimented caring practices might have once been ameliorated by sufficient and adequate inputs – food, heating, medical equipment, play and learning equipment - and sufficient numbers of well-trained carers and teachers. Childcare provision today, however, has come under enormous stress because

of the economic crisis. Carers struggle to carry out basic care tasks with inadequate and insufficient supplies and support. At the same time, the negative affects of outdated and inappropriate practices, exacerbated by the overall deprivation in the society, sometimes endanger not only development and protection rights of the child, but also the fundamental right of survival.

A minimum number of carers per children is fixed by law. Field observations indicate, however, that the ratio of children to carers is high. Even in ‘normal’ times, a high carer/child ratio results in available time being spent on basic tasks such as cleaning, feeding and dressing. Time is not then available for the necessary psycho-social stimulation of the child through play and learning activities. In the time of crisis which has characterised much of the 1990s, when carers must cope with increased illness, lack of available clean water, inadequate sanitation, lack of food and lack of medical supplies, even basic care functions have become threatened. Demotivated care givers, working in stressful environments in which food, medicines, heating, regular and safe water supplies, are in scarce supply, are often then not able to provide the standard of care required – particularly for the severely and moderately malnourished child living in baby homes, orphanages and boarding-schools.

Lack of food directly threatens the child’s life. Although food for children’s institutions is being largely supplied by the international community, its nutritional quality is low. Carers have to cope with disease and damage to the child’s health caused by micronutrient deficiency – such as lack of Vitamin A, iodine deficiency and iron deficiency. Basics such as soap, clothing, water are not available on a regular basis and so it is difficult to maintain cleanliness and basic hygiene practices. The crisis therefore has placed extra demands on carers and the institutional structure of public provision at a time when it is least equipped to deal with them. Carers, for instance, have to learn how to treat children suffering from malnutrition. Carers must also learn to identify and refer children with previously less common diseases such as tuberculosis and polio. Children have a high incidence of diahorrea as water and sanitation services are compromised and carers have an increased burden as they struggle to keep children clean and to maintain adequate hygiene standards. The country’s isolation has resulted in the continuation of outdated care practices and a lack of awareness of modern drugs and their associated management. Current practices which are potentially harmful to children, particularly when they are already physically very vulnerable, include the over-medicalisation of children’s care and the inadequate management of diahhorea. Over-medicalisation of care results in children being institutionalised away from families for long periods of time in facilities which are inadequate and inappropriate – for instance the baby homes and orphanages. Diahorrea management practices have emphasised the withholding of food and fluids from the child whereas optimal practice would be to maintain food and fluids combined with oral rehydration. Lack of awareness of modern drugs results in inappropriate drugs being prescribed in an inappropriate manner – for instance antibiotics for the control and management of diahhorea. Inappropriate use of high energy milk can result in ineffectiveness (if diluted too much) in the support of children with severe malnutrition. At worst, high energy milk which is not diluted enough, and perhaps contaminated by unsafe water supplies, can result in the death of a child. c) possibilities

On the whole, a relationship has developed between the international community and the government which has enabled some progress to be made in responding to the crisis facing children and women in the late 1990s. The international community has thus far worked with central and local authorities and to a certain extent at the institutional level. Reports indicate that children who maintain regular attendance at the children’s institutions are, on the whole, able to maintain and improve their nutritional status, even if there could still be some improvement. Reports indicate that those children now most at risk are those that for one reason or another are not in regular attendance in the institutions. The concern may now be to reach children in the wider community and who by definition are slipping through the institutional net. Given the social organisation and culture of the country and its continued commitment to collective voluntary organisation, one possibility that might well be explored would be to work with the women’s and youth organisations, particularly in training activities. These organisations have universal coverage, credibility in the communities and some record of achievement in mobilising their members– for instance in harvesting and planting times. In the rural areas, it may be useful to work directly with cooperative farm managements who have had a history of providing social services and who are closely attuned to the needs and requirements of the families who work and live within their confines.

1.1 ii Differences in children’s experience

Not all children and women have been affected in exactly the same way by the crisis of the 1990s. Cross-cutting cleavages of age, gender, rural/urban location and differentials in access to resources have had a variable impact on individual children and women. The following sections therefore evaluate the differing experiences of children and women as they are manifested over the life cycle of children and women. Given the difficulties in access to reliable information on the DPRK, the following analysis is to a certain extent somewhat speculative, although it remains founded in the knowledge base available, as outlined in Sections 1 and 2 of this report.

1.1 iii Table: child survival, development, protection and participation: threats and causation The following table provides a synopsis of the problems facing children and women at various stages in the life cycle. These are further adumbrated and

evaluated in the following pages First year of life 12 month to 5 years 6-12 year Adolescent and youths Women and mothers Manifestation Mortality, Morbidity

Malnutrition, Orphan Mortality, Morbidity Malnutrition, Orphan, Stunting, Wasting

Mortality, Morbidity Malnutrition, Orphan, Stunting, Wasting

Morbidity Malnutrition, Stunting, Wasting

Maternal mortality Malnutrition, Anaemia, Miscarriage, Stillbirth

Survival and Growth

Development and Protection

Survival and Growth

Immediate Causes

Physical injury, Disease, poor health and nutritional status of mothers, inadequate perinatal care, Immune deficiency, lack of exclusive breastfeeding, delayed complementary feeding, low immunisation coverage, death/sickness of parents

Micro-nutrient deficiency, inadequate dietary intake, disease

Lack of parental supervision/ involvement

Micro-nutrient deficiency, inadequate dietary intake, disease

Lack of parental supervision/ involvement

Micro-nutrient deficiency, inadequate dietary intake, chronic disease

Inadequate, imbalanced and inappropriate food intake, micronutrient deficiency, shortages of teaching and learning materials

Inadequate emergency obstetric care, delayed referral, inadequate food intake, haemorrhage, heavy workload, stress

Underlying Causes

Food insecurity, inadequate health care, unhygienic environment, micronutrient deficiency

Poor psychosocial stimulation, micronutrient deficiency, knowledge gap

Lack of vaccination, knowledge gap/poor case management, unhygienic environment, poor health facilities, lack of diagnostic equipment and drugs

Inadequate stimulation/ care, knowledge gap, low ration of care-givers to children

Inadequate stimulation/care, knowledge gap, low ration of care-givers to children

Insufficient resources in schools

Unhygienic conditions, inadequate health care

Inadequate care, lack of appropriate psycho-social stimulation

Lack of transport, knowledge gap, micronutrient deficiency, inadequate health care, unhygienic environment, lack of medicines and medical equipment, discontinuation of local drug production

Micro-nutrient deficiency, knowledge gap

Structural Causes

Economic difficulties, natural calamities

Lack of resources

Economic Decline And Natural Calamities

2. The first year of life 2.1 Introduction Based on DPRK census information, the total child population aged under one at 1998 was around half a million. The DPRK had seen stunning success in reducing the infant mortality rate from 204 per thousand live births in 1945 to 13.9 per thousand in 1995. Since 1995 the infant mortality rate (IMR) has started to increase again. By 1996, the official infant mortality rate was 23 per 1000 births, although the figure for 1999 is probably higher, particularly in outlying areas with the worst access to food supplies, health and social services. The 1993 DPRK census indicates the lowest IMR in the Nampo city area at just under 10 deaths per 1000 live births – with the highest IMR in Kangwon province at just over 16.

In 1999, infants face the dangers of death, sickness and disease, inadequate growth, malnourishment and the threat of losing parents because they themselves have succumbed to illness and premature death. For those children who do survive infancy, there are also concerns about threats to development and protection rights. 2.2 Survival 2.2 i Prior to the crisis

DPRK government studies in 1988 and 1991 of a child population aged between three months and 71 months in Kangwon province and Hyangsan country, respectively, (see Section 2, 4.4.i) indicated that children between three and five months had a satisfactory nutrition status as far as WHO standards were concerned. However these studies also identified mild malnutrition in 17 to 37 per cent of children (depending on the indicators used). Moderate to severe malnutrition was recorded in three per cent of girls and 1.8 per cent of boys. Growth started to falter from six months to 17 months. Children aged six to 18 months were significantly below WHO standard in all indicators. These results probably indicate that the conditions in some parts of the country were already contributing to infant malnutrition, prior to the crisis of the mid-1990s. They also suggest that the roots of malnutrition began in the weaning period, probably because of the unavailability of adequate and/or sufficient weaning food.

At the same time, there are no indications that malnourishment was a nationwide problem. UNICEF reported in 1985 that the average birth weight was 3 kg to 3.1 kg and seldom below 2.7 kg (See Section 2, 4.4). Low birth rate, a major indicator of malnutrition, was reported to have a prevalence of 5.5 per cent. This figure would not indicate widespread malnutrition at that time.

2.2 ii The 1990s

In the 1990s, the deterioration in public provision of basic goods has meant that the threats to the infant’s survival are more visible and more acute. Although there has been some difficulty in obtaining precise indicators of need, the joint government/international agency surveys and various field reports offer substantial evidence of threats to the infant’s survival. Infant mortality rates are high. There are also high morbidity rates, a widespread prevalence of malnutrition and an increasing numbers of children being placed in baby-homes because of the absence of parental or family support. 2.2. iii Low birth weight

Low birth weight indicator is a major indicator of poor growth in infancy and throughout childhood. The September 1998 MICS indicated (See Section 2, 3.4 ii) that just over 20 per cent of births are of babies of 2.5 kg and below. There was no substantial difference in the mean birth rate in urban and rural areas. These findings are of some concern given that the WHO has recommended that newborns with a birth weight of less than 2.5 kg should be considered to fall in the low birth weight category. LBW babies face a greater risk of perinatal and neonatal morbidity and mortality and risk substantial growth and development problems in later life. 2.2 iv Food supply

There is evidence from the MICS that children under six months received more meals per day – ranging between 3.2 and 8.9 meals - than slightly older children, with 96.6 per cent being breast-fed. Some 85 per cent of under six month old infants were exclusively breast-fed. The mean age at which breast-feeding stopped was between 4.9 and 9.3 months. Again according to the 1998 MICS, complementary or weaning food was introduced to infants at between the age of 2.9 months and 7.5 with children less than six months being given watery porridge. Evidence from field reports indicates a lack of availability of appropriate and adequate weaning food. International community food support to the nurseries provided cereals but these foods lack essential vitamins and minerals which are needed for adequate infant growth and survival. 2.2 v malnutrition The 1998 nutrition survey indicates that 32.2 per cent of infants aged 6 to 12 months are underweight with this rising to 46.7 per cent for boys and falling to 21.6 per cent for girls. In the same age group, 17.6 per cent had low weight for height (wasting) – an indication of acute malnutrition and 14.5 per cent had a low height for age (stunting) – an indication of chronic malnutrition. Although very precise delineation is impossible for all the reasons outlined in this report, the major contributory factors to malnutrition are probably low availability of quality food, including the lack of suitable weaning food, poor weaning and breast-feeding practices, diarrhoeal disease, breakdown in water, sanitation and hygiene conditions, social disruption including the loss of parental and familial support and the increasing incidence of tuberculosis. The 1998 MICS documented high incidence of diarrhoea 20.3 per cent), runny noses (20.5 per cent, cough (17.2 per cent) and fever (15.2 per cent) among under 5s – with no sex or age differences noted in the prevalence of these conditions. 2.2 vi inadequate health care

Lack of medicines, medical equipment and basic supplies for hospitals and clinics inevitably leads to threats to the infant’s survival. In addition, if the mother is ill or busy at work trying to earn income, the quality of the infant’s care will be affected. The 1998 MICS also found that substantial numbers of children had not received necessary vaccines by their first year of life.

2.3 Development and protection

Some of the contributory factors which threaten the infant’s right to survival, also threaten sound and safe development. Food deficiencies lay a base for vulnerability to disease and damage to growth potential. In addition, given the over-stretched care facilities, there are real dangers of inadequate psycho-social stimulation, particularly as care staff often remain unaware of contemporary developments in effective care practice.

Long term development rights of the child can also be affected from before birth if the mother’s nutritional status is damaged as is undoubtedly the case in the DPRK. Contemporary research indicates that poor nutrition of the pregnant woman can have very profound affects on later child development – including delayed motor development, an affect on cognitive development such as to result in diminished IQ, a greater degree of behavioural problems at school-age and generally lower educational achievement.

2.4 The orphaned child

The DPRK had historically focused care and support on war orphans and had done so, partly in the provision of three types of residential institutions each catering for different age groups. The babyhomes take children from birth through to five years old. The orphanages take children from six to eight years of age. The boarding-schools take children from 9 to 18 years old. After the war, adoption became a norm. Reports indicate that prior to the crisis the numbers in institutions designed for the orphaned child had diminished as war orphans became adults and left the institutions.

Since the crisis, however, the population of children’s residential institutions has increased. Baby homes with a population of 50 some five years ago are in 1999 home to over 200 children. Some of this population increase is due to increased mortality of parents. Some of it, however, is due to the fact that increasingly destitute parents are leaving children in these institutions for temporary periods so that children can have access to food and other basic

supplies. In 1999, reports indicate that the numbers in these institutions are stabilising. Given reports indicate that here is still widespread prevalence of child malnutrition and the country still suffers from food shortages, it may be that parents and/or relevant authorities have decided that these institutions cannot guarantee adequate and appropriate care, and are searching for other solutions to distress.

Many of the children in these institutions live in difficult conditions. Although these institutions, particularly the baby homes and orphanages, have been intensively supported by the international agencies, children still often experience food inadequacy, insufficient medicines and health support, and lack of heating and electricity and compromised water supplies. In addition, because of the huge over-stretching of care-takers, care and attention is often only available for the most basic tasks – such as feeding and helping children stay clean. Even these basic tasks are sometimes not fulfilled effectively. Such stress on these institutions and the care-takers, themselves dealing with lack of food and income, leaves little time for play and learning activities or of emotional support for the children. Many of these institutions therefore are depressing environments for children, lacking stimulation for development and the ability to meet the individual child’s needs.

The nutrition survey indicates that children without parental support have a higher risk of suffering from severe malnutrition. It is also generally well-known that appropriate psycho-social stimulation can assist in a more rapid recuperation from malnutrition. Any strategy for improving conditions for the orphaned child therefore would need to concentrate on both reducing child numbers in the institutions and providing support for the family in the community so as to offer alternatives to residential care. At the same time, ongoing support is needed to assist institutional care-takers with supplies, training and better facilities for carrying out their work.

3 One year to under 5 3.1 Introduction

Based again on DPRK census information, the number of children aged under five is just over 2 million. The official 1996 under five mortality rate was 15 per thousand although some reports indicate for 1998 a figure of 39.3 (See Section 2, 3.4 v). Even though there is no guaranteed accurate figure, what is agreed is that in 1999 there is an unacceptably high level of under five mortality. Again the figures are likely to be higher in outlying areas, for exactly the same reasons as for likely high levels of infant mortality in these areas. These include poor access to food supplies, health and social services

In 1999, as with infants, under 5s face dangers of death, sickness and disease, inadequate growth, malnourishment and the threat of losing parents because they themselves have succumbed to illness and premature death. One important difference is that, according to the 1998 nutrition survey, the prevalence of low weight for height (wasting) which is a sign of acute malnutrition is higher in the age range 12 to 35 months than in any other age range between 6 and 84 months. Such severe malnourishment, if not treated adequately, will threaten both the survival and the development rights of the child.

In addition, children from 12 months to 4 years old see some rights to development and protection threatened as overstretched nurseries and kindergartens lack resources for psycho-social stimulation and parents are unable to care for their children effectively because of economic hardship. 3.2 Survival 3.2 i Prior to the crisis DPRK government surveys (see Section 3, 2.2 i above) of children between 3 months and 72 months indicate that malnutrition had been a concern of the government in some areas of the country. A 1985 UNICEF report had estimated a malnutrition incidence of around five per cent in pre-school children although it had also indicated that obtaining data on nutrition had been difficult. Micronutrient deficiency existed prior to the 1990s, and was perceived a particularly problematic in mountainous regions. The 1988 DPRK survey of Kangwon identified iodine, Vitamin C, Vitamin A, Vitamin D and iron deficiencies (See Section 2, 4.4 i). However, there is little evidence to indicate that micronutrient deficiency in young children was a nationwide concern. In 1985 UNICEF reported for instance that there was no local name for night-blindness (from Vitamin A deficiency) and there were no nation-wide statistics on the prevalence of anaemia (from iron deficiency). 3.2 ii The 1990s

In the 1990s, the deterioration in public provision of basic goods directly threatened the young child’s right to survival. Under 5 mortality rates are high, increasing and in some areas could be reaching alarming levels. There is substantial evidence of threats to the young child’s survival and growth from the government/international surveys. There is an alarming and documented prevalence of acute and chronic malnutrition in this age group. These children also face high morbidity rates, an increasing incidence of institutionalisation as children are placed in baby-homes because of the absence of parental or family support, and care practices in the institutions which are sometimes ineffective and, in the worst cases, contribute to the threat to the child’s survival. 3.2 iii Food supply The 1998 MICS showed that the mean number of meals consumed by children under five years of age was between 2.3 and 4.5. Children under six months had more meals than older children, with the mean meal intake for children in their fifth year of life ranging between 0.7 and 3.5. Given that children are also extremely reliant on food assistance to the institutions from the international community and given the low nutritional value of this food, it is likely that this age group is used to receiving both insufficient food and inadequate food. Although the 1998 MICS showed hat vegetables and staples were the main food items given to children in this age group, there is no data on the quality or quantity of vegetables given to children. Given the country’s overall shortage of food, it could

reasonably be assumed, however, that any vegetables available would not contribute significantly to providing the micronutrients necessary for healthy growth. 3.2 iv Malnutrition

The 1998 nutrition survey indicates very high levels of malnutrition in this age group with boys being affected more severely than girls (See Table below). This age group witnesses the highest incidence of low weight for height in all children between 6 and 84 months which peaks between 12 and 35 months. Both before and after these ages, low weight for height (wasting) decreases. The 1998 nutrition survey also showed that low height for age (stunting) and the incidence of underweight children continued to rise through the fourth year and did not tend to decline thereafter.

The worst affected in this age group in terms of low weight for height (wasting) – an indication of acute malnutrition – were children aged 12 to 24 months. In this group, 30.9 children were suffering – with 36.5 per cent of boys affected and 25.8 per cent of girls. The worst affected in terms of low height for age (stunting) – an indication of chronic malnutrition – were children aged 48 to 60 months with 77.5 children affected. This included 80 per cent of boys and 75 per cent of girls. Although these were the worst affected groups, the statistics were just as stark for other children aged between 12 months and 5 years.

Low weight for height, indicating acute malnutrition, was recorded in 20.5 per cent of children aged 24 to 36 months and 13.4 per cent of children aged 36 to 48 months. Low height for age, indicating chronic malnutrition, was recorded in 75.1 per cent of children aged between 36 and 48 months, 62.2 per cent of children aged between 24 and 36 months and 48.5 per cent of children aged between 12 and 24 months.

The worse experience of children in this age group compared to the 0 to 12 months old children probably indicates that breast-feeding is providing something of a protection for infants. Children in this age group are reliant on access to adequate weaning foods and, as they grow older, food which can provide the nutrients necessary for healthy growth. The indications are that not only are children in this age group not receiving enough and adequate food for healthy growth but their food intake is so insufficient that children are becoming severely malnourished. Other major contributory factors to malnutrition are of course the lack of suitable weaning food, poor weaning and breast-feeding practices, diarrhoeal disease, breakdown in water, sanitation and hygiene conditions, social disruption including the loss of parental and familial support and the increasing incidence of tuberculosis. As pointed out in 2.2 v above, the 1998 MICS documented high incidence of diarrhoea 20.3 per cent), running noses (20.5 per cent, cough (17.2 per cent) and fever (15.2 per cent) among under 5s – with no sex or age differences noted in the prevalence of these conditions. Young children under two years of age are particularly vulnerable to malnutrition because their growth rates are very high at this age and adverse factors can have a greater potential for retardation than at later years. Young children have high nutritional requirements per kilogram of body weight and are immunologically naive and more susceptible to frequent and severe infections. In addition the very young child is unable to make their needs known and therefore vulnerable to poor parenting or poor institutional practices. Finally the ‘wiring’ of cognitive and emotional ability takes place in this period and malnourishment at his age, therefore, can have a profound affect on the child’s potential for growth and development. It is essential therefore that programmes of prevention focus on women during pregnancy and children under two years of age,

Prevalence of moderate and severe malnutrition by age and sex Males Females Total

Wasting (Wt/Ht < -2Z)

Percent Percent Percent

Age groups 6 - <12 months 19.1 16.5 17.6 12 - <24 months 36.5 25.8 30.9 24 - <36 months 25.3 14.2 20.5 36 - <48 months 16.3 9.2 13.4 48 - <60 months 14.6 3.0 8.9 60 - 84 months 11.7 4.2 7.8

Stunting (Ht/Age < -2Z)

Age groups 6 - <12 months 23.0 8.2 14.5 12 - <24 months 45.6 51.1 48.5 24 - <36 months 63.7 60.2 62.2 36 - <48 months 74.6 75.6 75.1 48 - <60 months 80.0 75.0 77.5 60 - 84 months 76.4 73.4 74.8 Underweight (Wt/Age < -

Age groups 6 - <12 months 46.7 21.6 32.2 12 - <24 months 63.1 49.4 56.1 24 - <36 months 72.1 61.5 67.3 36 - <48 months 69.1 70.3 69.7 48 - <60 months 66.6 56.6 61.9 60 - 84 months 70.1 59.7 64.7 (Source: UNICEF/WFP/EU/DPRK government nutrition survey, 1998)

3.2 v inadequate health care Similarly to the infant, lack of medicines, medical equipment and basic supplies for hospitals and clinics inevitably leads to threats to survival of the under 5. In addition, if the mother is ill or busy at work trying to earn income, the quality of the child’s care will be affected. The 1998 MICS found vaccination coverage was low and had decreased substantially since 1993. Only 63.9 per cent of children aged 12-23 months had BCG coverage (against tuberculosis). Only 37.4 per cent had received their third dose of DPT (diptheria, pertussis and tetanus) with the highest coverage reported for OPV (oral polio vaccine) at 76.5 per cent. Measles coverage was low at 34.4 per cent. (See Table below for detail). In 1999, however, improvements were recorded in this area. At the conclusion of the measles campaign in early March 1999, all children in the 0-23 months cohort had received measles vaccination. In addition in October and November 1999, a series of national immunisation days, the government assisted by the international agencies, implemented national vaccination against polio for children under five years of age. DPT immunization is also being revived.

Vaccination coverage

Source: Multiple Indicator Cluster Survey, 1998.

3.2 vi care practices Care takers in hospitals, nurseries, kindergartens, baby-homes and orphanages are certainly over-stretched. They find it difficult to meet basic needs of food, hygiene and health because of the lack of supplies in all basic requirements including food, safe water, heating, soap and medicines. At the same time they are having to cope with new problems of which they had previously no knowledge or training as to their diagnosis, control and management (See Section 2, 4.4 vii for detail) of malnutrition and formerly rare diseases such as tuberculosis. Carers had therefore to cope with both their ‘normal’ care-giving tasks in an environment of acute resource shortage and, at the same time, to learn and implement new strategies and practices for dealing with high levels of acute and chronic malnutrition in this age group. It is not surprising therefore that when already stressed caretakers came under criticism from international agency workers because of their adherence to medical practices and care practices they had been previously taught were appropriate, that there was some reluctance to implement change. However, some care practices such as the practice of managing diaohhrea by withdrawal of food and fluids, combined with inadequate oral rehydration practices are certainly harmful to children and urgently do need to be changed. Field reports indicate that antibiotic use is

BCG OPV3 DPT3 Measles TT2

1993 1998

poorly understood. One consequence is that in some children’s institutions, there is a failure to identify children a risk of death or complications and treat them intensively with intra-muscular antibiotics. This may be an area where intensive non-governmental organisation involvement at the local level could work to constantly reinforce previous training and could assist directly in saving children’s lives. 3.2 vii slipping through the ‘net’ Although there is concern about institutional practices, there is also a recognition that the children’s institutions and the hospitals provide a food and health safety-net in that international assistance is channeled through these institutions. There is some concern for children living in areas where international assistance is not available (because the government does not allow monitoring) or who, for one reason or another are not reaching the institutions. Given the overall conditions of the country, children who do not receive international assistance are likely to be in an even worse state of malnutrition than those being seen in the institutions. This probably means that these children disproportionately face a high threat of death. One strategy to deal with this would be to channel international assistance through the Ri or Dong level public health institutions – including perhaps the local social organisations such as the Red Cross and the youth organisations. 3.3 Development and protection

Some of the contributory factors which threaten the young child’s right to survival, also, as with the infant, threaten sound and safe development. Food deficiencies lay a base for vulnerability to disease and damage to growth potential. The low ratio of care-givers to children in institutions also militates against the provision of adequate psycho-social stimulation, as care-givers struggle to deal with the immediate manifestations of malnutrition in terms of lack of food and insufficient medical and health support. There is also some concern that this age group suffers from insufficient parental involvement and supervision as women and men search for ways to enhance their income and continue to engage in the economic reconstruction of the country. Lack of parental support threatens the child’s right to protection.

4. The older child – from 5 to 12 years old 4.1 Introduction

There is little information on children above 7 years of ages. The 1998 nutrition survey did not include children of this age group. The 1998 MICS also focused on children under five and pregnant and nursing women. Field reports have focused on the plight of the younger child.

The numbers of children in the age group 6 to 14 are around 3.6 million (population census 1993). According to the 1998 MICS, 100 per cent of children are enrolled in school with a less than one per cent drop out rate. There is some concern about the threat to development and protection rights given the estimated impact of the economic crisis on the education and health services. There is little solid information about this group of children but there are concerns that the complex breakdown in public provision may also affect the right to survival of this group of children. The extent of threats to mortality, rates of morbidity, and the extent of malnutrition among this group are not well-known. The number of children in boarding schools is increasing, which indicates a rise in destitute children and orphans, but there is little reliable information on rates of increase and reasons for parental absence (See Section 2, 6.2 ii). 4.6 Development and Protection

4.2. i Prior to the crisis There is ample evidence that prior to the crisis of the 1990s, a child’s right to development was a high priority in the DPRK and a number of provisions were made to encourage the all-round development of the child. The child could expect to see their basic needs met and at the same time would have access to culture, sport and formal education. Children with handicaps and children with special abilities received particular attention and all children were encouraged to engage in various extra-curricular activities. Children had the opportunity to develop skills and talents in a way that many other societies could not emulate. At the same time there was a stress on collective achievement such that children developed individual skills within the context of a contribution to a wider group- whether this be the local children’s organisation or school or the nation as a whole. Individualism for its own sake was not encouraged. There was a degree of regimentation in the education system which may not have encouraged individual initiative. At the same time the child was encouraged to develop a high degree of social responsibility towards the community and the nation. 4.2 ii the 1990s

The DPRK has sustained its high level of enrolment in school despite the economic difficulties of the 1990s. This ensures some level of protection and access to means of development. Field reports in the education sector, however, indicate that schools are lacking heating, regular access to safe water supplies and adequate sanitation (See Section 2, 6.4. i). Schoolbooks, which are provided by the state, are still available but are fewer than before the crisis. The 1998 MICS indicated that primary school children received between 2 and 15 books with the median number received being 5 in 1998.

In the DPRK, children receive school meals but there is also concern that food is inadequate and insufficient, thus contributing to a difficult learning and teaching environment. Given that teacher’s working in the system will also be suffering from food deprivation as the Public Distribution System (PDS) has reduced rations and given their possible lack of access to alternative sources of food and income, particularly in the urban areas, it is likely that the quality of teaching will have been adversely affected. Such factors could contribute to poor psycho-social stimulation. There is also, however, some evidence to indicate that children continue to benefit from the DPRK’s commitment to extra-curricular activities in that urban children can be see taking part in organised dance and sporting activities which remain an essential part of DPRK education and cultural life.

There are still, however, concerns that children in this age group are over-reliant on institutional instead of family care. There are also some concerns that, because of the isolation of the country, teachers and carers have been insulated form contemporary developments in teaching and caring practice. In other words there may be a knowledge gap which affects service provision for these children 4.3 Survival

There is little direct data in this group of children in terms of mortality and morbidity rates. However, the 1998 nutrition survey (Section 3, 3.2 iv above) indicates that low height for age (stunting) continues to rise through the fourth year and does not show a tendency to decline thereafter. It is likely that all DPRK children have been affected in some way by food shortages, micronutrient deficiencies of environmental determination and disease. There is some concern about iodine deficiency particularly in the mountainous regions. Children in this age group will also have survival rights threatened by poor sanitation, compromised water supplies, and the more general breakdown in health services.

5. Adolescents and youths 5.1 Introduction

There is little direct data on adolescents and youths in the DPRK. For this reason no definitive conclusion could be made about the situation of this group of children. It is possible to make some qualified speculative analysis based on observation and the comparative experience of other countries although it is clear that much more information is required before an adequate analysis of the situation of these children in the DPRK can be made. 5.2 Development and protection 5.2 i Prior to the crisis

The DPRK made huge investments in its youth. Education services guaranteed secondary education which starts at age 10 where children attend the senior middle school until they are 16 years old. They may then attend universities and colleges until they are 22 and the possibility is also available to undertake postgraduate education until age 26. At the end of the second world war there was not one institute of tertiary education in the DPRK. By 1989 there were 235 universities and 473 colleges.

In addition, all children over 13 are members of the Kim Il Sung Socialist Youth League where they are encouraged to develop cultural and sports skills – as well as to participate in social mobilisations. Some of these are locally based, such as helping in the local community. Others are national tasks and can include being mobilised to take part in planting and harvesting. Reports indicate that children in this age group also are prepared to help defend the country should need arise. Part-time education is stressed for older children in work and factories and farms were strongly encouraged to provide educational facilities for their workers. 5.2 ii the 1990s

The DPRK has reportedly managed to maintain a very high level of enrollment in its schools despite the economic problems facing the country. According to the MICS, the DPRK still managed to achieve almost 100 per cent enrollment in children aged between 7 and 16 years in 1998. Textbooks provided by the state were cut back but the education system still managed to allocate secondary school children between 2 and 15 books per pupil in 1998. Again according to the MICS, 38 per cent of children at secondary school (between 10 years and 16 years) received more than 8 books in 1998. The continued functioning of the school system goes some way to promote the development and protection rights of children. There are some concerns that economic stress on the family may have led to a weakening of family care as families rely on the children’s institutions to provide food and shelter for their children. Juvenile delinquency is not reported as a major problem in the DPRK and here are no signs of gangs of children wandering aimlessly around the streets which is often a sign in other countries that the child’s rights to protection are endangered. 5.3 Survival

This group of children may be at risk from chronic disease particularly given the rise in the incidence of tuberculosis. In addition, respiratory diseases and diahhorea are likely to be increasingly prevalent given the nation’s overall food shortages and the deteriorating water and sanitation infrastructure. On the other hand, the DPRK still manages to uphold child rights to survival in ways which developed countries do not. For instance, there is no reported HIV/AIDS in the country. There are no reports indicating drug abuse in the DPRK. There is little information on the prevalence of sexually transmitted disease but there have been no indications that this is a major problem.

6. The adult – women and mothers 6.1 Introduction

Women have been supported in the DPRK legally, in terms of a commitment to formal equality with men, and institutionally in terms of the provision of nationwide childcare facilities. As a consequence of extensive childcare provision, women were able to enter the labour force in large numbers. Women also participated in nation-building tasks outside the workplace – in voluntary, collective efforts often involving hard physical labour. There is some evidence that food shortages have affected the country for at least a decade and these, combined with the physical burden carried by many women, have probably led to a decline in health and nutritional status. Low height for age (stunting) has occurred. Although there is no data as to the extent of the problem, field observations indicate that it could be extensive.

The crisis of the 1990s has exacerbated the downward spiral in women’s health and nutrition standards. Chronic malnutrition combined with further cuts in dietary intake in the mid-1990s - with the associated lack of appropriate micronutrients – along with deteriorating prenatal care would undoubtedly contribute to low birth weight in new borns. For women and mothers in the DPRK poor nutrition and inadequate health care affects therefore not just themselves but their unborn children and their capacity to nurture children after birth.

For women themselves, the economic crisis of the 1990s raises some challenges in respect of previously attained development, participation and protection issues. There are threats to survival as far as these women are concerned – most worryingly seen in the increase in maternal mortality. The survival of the unborn child is also threatened if the mother suffers from nutrition and health care deficiencies. In additions, the young infant who relies on breast-feeding for a healthy start to life is potentially harmed if the mother is unable to care for the child. 6.2 Development, protection and participation 6.2 i Prior to the crisis

Women were granted formal legal equality with men in 1946. Women were encouraged to participate in the workforce through the provision of universal child care – resulting in one of the highest labour participation rates in the world. Women workers were guaranteed paid maternity leave and mothers with three or more children were by law able to work a 6 hour day but be paid for 8 hours work. Women were also permitted time off from work to breast-feed infants. Workplaces and children’s institutions provided food with the overt rationale that women would have to do less cooking. One of the reasons given by President Kim Il Sung for the stress on technological development was to provide time-saving domestic appliances – again explicitly designed to ease the domestic burden on women. Women’s social (gender) roles remained therefore the same in that they were still perceived as the primary care-takers in DPRK society. What did change, however, was the commitment to ease the domestic burden on women. 6.2 ii The 1990s

One if the consequences of the economic crisis of the 1990s was that public institutional and collective provision of support for women and children began to break-down. In addition, although heavy industry began to shutdown, service and light industrial sectors were maintained and expanded. This meant that better-paid jobs were lost with low-paid, low status jobs in service work and light industries (public health, domestic work, catering, textile production, for example) remaining. Income from this work has been reduced in value as the won becomes worth less against the increasingly ubiquitous dollar in the DPRK economy. Women make up the work force in the service and light industrial sectors.

The social organisations within which women often play an active part, continue to be mobilised to help in economic and agricultural reconstruction. Women are, therefore, likely to be still working, both in their official workplace and in collective social reconstruction, often in physically demanding work. At the same time women, as the primary care-takers, have to cope with the responsibility of providing food and basics for the family given that insufficient food, sometimes none at all, is available through the public distribution system and/or in many workplaces. There is also some evidence that working women are no longer able to benefit from the legal provision which allows time off for breast-feeding. There is some concern therefore that the extra burden of fending for the

family combined with high workloads with diminished support threatens women’s rights to development, protection and participation. Given the national commitment to easing the burden on women, it may be that once the country has time to take stock of these new challenges threatening women’s rights, a new strategy will emerge to cope with these new circumstances. 6.3 Survival There has been an estimated rise in maternal mortality (See Section 2, 3.4. iv) from 41 per 100,000 live births to 105 per 100,000 live births in 1996. It is likely, given the general lack of drugs in the health system, the lack of food in the country and the known prevalence of anaemia (See Section 2, 3.4 iii) that these figures could reflect underreporting. It is also very likely that rates of maternal mortality are higher in some regions of the country than others. Although there are no figures available, it has been reported that there have been increases in the incidence of miscarriage. The 1998 MICS revealed that all women in the DPRK have access to a comprehensive schedule for antenatal care with no significant difference between urban and rural areas in terms of access to retained health care support. Increases in miscarriage therefore are more likely to be due to the general condition of malnutrition in the country, heavy workload and poor health care rather than due to inadequate access to antenatal screening. Although there are no figures available, here are also concerns about possible high perinatal mortality rates. Increased perinatal mortality is a likely consequences of the known problems of maternal nutritional deficit, the sometimes delayed referral of mothers with complications to specialist institutions, the lack of adequate emergency obstetric care, particularly in the provinces. Finally, a worrying development since the mid-1990s has been the increase in the number of children placed in baby-homes. Mothers have either died or are not in a position to care for children. Furthermore admission to a baby-home is a sign that family and community support networks have weakened. This is a worrying development given the previously strong community support for adoption. The 1998 nutrition survey has also demonstrated that infants without parental support run high risks of suffering from severe malnutrition and therefore of increased risk of death.

Section 4 Trends, areas of concern and strategies for the future 3 Trends

Prior to the economic crisis of the 1990s, the DPRK had built up an impressive array of social infrastructure which provided the framework from within which the child’s rights to survival, development, protection and participation were implemented. The long term decline which started to become visible in the early 1990s, combined with the devastation caused by natural calamities in the mid-1990s, wreaked destruction on this social infrastructure.

The DPRK sought assistance from the international community in 1995 as it became unable to adequately feed its population. Children were visibly affected and acute malnutrition was observed in various parts of the country. The international community responded with food and other emergency aid that was initially targeted on the most vulnerable in the population: children under seven years old and pregnant and nursing women. The international humanitarian community sought detailed information on the scale and scope of malnutrition so that the various agencies could both plan effective interventions and assess the impact of assistance. Donors were also concerned that international aid should not be diverted to non-intended beneficiaries. 3.1 The prevalence of child malnutrition

In 1998 the government and the international community worked together to produce a joint nutrition survey and UNICEF and the government carried out a Multiple Indicator Cluster Survey (MICS). Together with field reports these surveys indicated a nationwide problem of child malnutrition which probably affected the adult population in an equally widespread manner. The 1998 surveys were the first scientific surveys completed on the scale of malnutrition although there had been a previous survey in 1997 which had non-random access to children’s institutions. Even though there were, therefore, clearly difficulties in making comparisons between 1997 and 1998, the tentative results that could be ascertained indicated that there had not been a decline in acute child malnutrition. The 1998 survey also indicated an increase in chronic malnutrition as perceived through the increase in low height for age (stunting). Although differences in survey methodology could contribute to the assessment of a large increase in low height for age (stunting), the high rate of low height for age would not be a surprising result. This is because of the continued food shortages in the country and the high prevalence of micronutrient deficiencies, morbid conditions, particularly diarrhoea and acute respiratory infections in children. High low birth weight figures also are an indication of chronic malnutrition. The malnourished child is therefore situated in an increasingly vulnerable environment with a sometimes deteriorating nutritional status and, if the child is in a residential home, without the benefit of family care. 3.2 From 1998 to 1999: changing priorities

It is difficult to assess what changes have occurred between 1998 and 1999 as no new nutrition survey or MICS was completed in 1999. The data therefore comes from field reports and professional assessments of those working in the country. The main findings from these sources is that although children are still chronically malnourished because they are still receiving insufficient food which is also inadequate because it lacks appropriate nutrients, those children who regularly attend children’s institutions are now relatively better protected against acute malnutrition than those who do not. This does not mean that children’s institutions in the DPRK are in a position where they can respond to all the rights of the child in term of survival. They often lack adequate food, heating, constant access to safe water and sanitation and there are some areas of care and health practice which are not always conducive to the child’s well-being.

The changing concern in 1999, however, is about children who for one reason or another are not attending children’s institutions and who are suffering from acute malnutrition. These children will only have access to ri health service facilities which are without basic medical supplies and drugs and which do not have the facilities and inputs to give the emergency treatment necessary to prevent these children from dying. It is not clear why these children are not reaching appropriate medical care. It could be lack of transport, inadequate referral systems or lack of knowledge about what is available. It could be that families are unwilling to leave children in residential care a long way from home particularly if they are not convinced that the quality of care they would receive in the baby homes and orphanages for instance would be such as to benefit their child.

Another concern remains those children who may attend institutions but who may not be in receipt of international assistance. This would apply to those children living in counties which are not accessible to the international community. In 1999, there is still no information available on the scale of need in these counties. Further information also is not available on the scale of need of children in residential homes for handicapped children. Although UNICEF received some information on these homes in 1998, it has not yet been possible to follow up this information so as to devise and implement appropriate programmes of assistance.

In 1999 the international community continues to implement programmes designed to deal with the treatment of acute malnutrition but is also attempting to engage in a preventive strategy to try to deal with some of the underlying causes of malnutrition. This involves attention to the quality of food as well as the quantity; health and care practices in institutions and outside them - such as the improved management of diaohhrea; assistance with the provision of safe water and sanitation; and disease control and management.

In terms of agency organisation, the gradual move towards decentralisation as carried out by some NGOs seems to be providing useful support for local authorities attempting to deal with malnutrition. Reports indicate that where NGOs are active in a local area they are able to help provide a reliable and efficient level of support particularly to the children’s residential institutions. This practice should be strongly encouraged and supported.

3.3 the macro level

Indications are that there will continue to be a large shortfall in the grain harvest next year. This will entail a continued reliance on international food aid. The international political external climate is looking more propitious than in 1998 with various major powers involved in negotiations of different kinds with the DPRK. These negotiations could unlock the door to international loans which could assist in recuperation of public infrastructure such as water supply and electricity regeneration. However even if such positive developments continue they will take some years to come to fruition. On the other hand changes in government in some of these major powers could change the external situation in a way which would be detrimental to the prospects of major capital investment, or even to the continued provision of international aid.

In the short to medium term, therefore, international humanitarian assistance is likely to continue to be necessary to deal with challenges to the rights of the child to survival, growth and development.

4. Areas of concern The following areas of concern emerge from this situation analysis of children and women in the DPRK in 1999. Health concerns have been subsumed under the following headings. Partnership issues are also included in the following categories. The four areas identified are

data collection, collation, systematisation, analysis and dissemination continued child acute and chronic malnutrition children in need of special protection support of women and mothers

In each category a number of recommendations are made, again based in the findings of the situation analysis. *Data collection, collation, systematisation, analysis and dissemination Recommendations: (i) The agencies should consider targeting the babyhomes, orphanages and boarding-schools so

as to establish a common data base on these institutions. A common report form could be designed with space for quantitative and qualitative input. Residential and non-residential agencies should be asked to complete this form when they visit these institutions. UNICEF would be well-placed to collect, collate, systematise, analyse and disseminate this information on a regular basis. At the same time this information would provide a solid and constantly updated data base to assist UNICEF to devise and implement programmes.

(ii) It may be useful to have a designated agency for each province (along the lines of current

health responsibilities for instance) responsible for ensuring that reports on that province’s babyhomes, orphanages and boarding schools are compiled and returned to UNICEF. It would be useful to support NGOs which want to work in specific provinces so that they can focus on specific support to specific babyhomes, orphanages and boarding schools such as to act as pivotal and reliable channels of support, care and programme planning between the institutions themselves, local authorities, the government and the UN agencies. The successful example of NGOs’ involvement at the provincial level provide a workable framework.

(iii) Where there is significant overlap in work at the ri level with other agencies it may be useful

to consider how much common reporting could be done on the lines set out in (i) above. This is so as to ensure that strategies and programmes can be put in place so as to assist children falling through institutional nets.

(iv) Annual nutrition survey and Multi Indicator Cluster surveys (v) It would be useful to also focus on identifying needs of the older child (over 7 years) of which

there is little information (vi) More systematic recording and analysis from already agreed sentinel sites should be

undertaken. It may be useful to have a designated person whose responsibility it is to report regularly on sentinel sites and what information has been obtained from them to CMT.

(vii) The very useful UNICEF monthly reports should continue and be disseminated more widely,

perhaps internationally on the internet and by email as WFP does with its monthly reports. * Continued child acute and chronic malnutrition

Recommendations (i) closer support of children’s residential institutions (see above) (ii) focus on care practices and case management (iii) specific reinforcement on management of diaohhrea (iv) specific reinforcement of appropriate drug regimes (v) focus on prevention of wasting, reduction of stunting and control of micronutrient deficiency (vi) focus on preventive strategies including support for water, sanitation and hygiene

management (vii) focus on disease prevention (including immunisation) and support for disease surveillance

management (viii) promotion of breast-feeding (ix) urgent inputs into the provision of adequate weaning food (x) continued support for provision of children’s soap and necessary cleaning materials for

residential institutions, hospitals and schools (xi) to investigate working with the youth and women’s organisations on support for good hygiene

practices, disease prevention, etc (xii) with the government and other agencies, to urgently devise an appropriate strategy to respond

to the needs of children falling outside the institutional net (xiii) the entire under two child population should be targeted for adequate complementary

food assistance and micronutrient supplementation * children’s residential institutions (i) to work with the government to assist care givers in training, inputs and perhaps to encourage

increased staffing levels (ii) to urgently identify the needs of handicapped children in residential institutions and to devise

programmes to respond to their needs. This could be done with the assistance of a specialist NGO like Handicap International for instance with which the government has already some contact

(iii) to work in a more targeted manner in respect to residential children’s homes (see above) (iv) to provide assistance through facilitating study trips abroad for instance to teachers and

education planning so that they can become familiar with contemporary learning and teaching methods

(v) to provide assistance through facilitating study trips abroad for instance to care givers and

child care policy makers to permit them to become acquainted with some of the child development ramifications of institutionalisation of children

* Support of women and mothers Recommendations (i) The international community should extend its food and micronutrient vitamin supplement to

girls (and boys) in schools (ii) Food assistance to nursing mothers should be extended until the child is at least one year old (iii) UNICEF should consider:

• working with the National Democratic Women’s organisation to develop reinforcement strategies for good breast-feeding practices and

• with appropriate social organisations on the development of training programmes which could then be transferred to the communities and

• with the government to identify a programme designed to contribute to the reduction of maternal mortality. This may mean designing ways in which ri level health service could deliver improved obstetric care and detect complications earlier so that referral to a specialist institution could be made in a timely manner

5. Strategies

UNICEF and other agencies first became involved in an intensive manner in the DPRK because the emergency situation of food shortages in the mid-1990s and the immediate threat to life of children and women. While there us still an acute situation facing large numbers of children and women and therefore a need for an emergency and curative response, the challenge facing the DPRK and the agencies is to move at the same time to a strategy based on prevention.

Such a strategy demands efficient and mutually trusting relationships between government, UN and other agencies and non-governmental agencies. This does not mean that there will not continue to be some disagreements on certain issues. However it is certain that without good collaborative relationships children will continue to slip through the net of assistance in the short term and, in the long term, another generation would risk growing up suffering from chronic malnutrition and diminished life chances. Thus survival for some and development and protection rights for large numbers of children would be threatened.

A first strategic priority is to continue to develop and maintain good working partnerships with all involved authorities.

Dealing with acute and chronic malnutrition also demands a multi-sectoral approach if it is to succeed. Health, nutrition, water, sanitation and education strategies and programmes need to be integrated into a comprehensive strategic whole if the complex causation of malnutrition is to be addressed effectively.

A second strategic priority then is to develop and implement a multi-sectoral approach to malnutrition in the DPRK.

Children function within the DPRK society in different sorts of social settings. These include the family, the institutions, the social organisations and the wider community. Women also carry out activities in different social frameworks: as care-takers in the family, as workers often in low paid and arduous jobs and in the social organisations where they take part in nation-building activities. Thus strategies designed to address children’s needs and support child rights need to be designed with these contexts in mind.

A third strategic priority is to design and implement programmes within the appropriate societal context in order to more effectively reach children and women and respond to their needs.

Children and women are all individuals with different life experiences, needs, personalities, expectations and prospects. While it is not possible to design programmes to deal with each individual person it is possible to add some refinement to programmes if information is available by age, sex and geographical location. The DPRK government had historically expressed concern over the relative deprivation of children living in mountainous regions for instance. There is also very little knowledge about the specific situation of the older child and adolescents and youths. Efforts should then be made to identify the specific requirements of children with specific needs.

A fourth strategic priority is to obtain information to try to understand the specific needs of different ages groups, sex and geographical location.

It is difficult to predict the pace of economic recovery and therefore the extent of continued need for emergency inputs such as food and vitamin supplements. A strategy should be adopted, however, that combines elements of a prevention-based work approach with curative support necessary, for instance, for dealing with acute malnutrition.

A fifth strategic priority is to combine assistance for prevention with programmes designed to cope with acute need.

List of Sources DOCUMENTATION DPRK GOVERNMENT National Education for All (EFS) Assessment report, ‘The Implementation of the “World Declaration on Education for All”’, National EFA 2000 Assessment group, DPRK, September 1999 Organagram of ministries, November 1999 FAO/WFP FAO/WFP crop and food supply assessment to the DPRK, 8 November 1999 OCHA United Nations Consolidated Inter-Agency Appeal for DPRK January-December 1999, Office for the Coordination of Humanitarian Affairs (OCHA), New York, December 1998 1998 Annual report of the UN resident coordinator in DPR Korea, 31 January 1999 UNICEF Draft Situation Analysis DPR Korea 1997, June 1997 An Analysis of the Situation of Children and Women in the DPRK, draft, UNICEF Pyongyang, May 1998 Annual Report 1998, UNICEF Pyongyang Government of the DPRK and UNICEF Master Plan of Operations 1999-2000, UNICEF Pyongyang Project Plans of Action, UNICEF DPRK Emergency Programme, January-December 1999 Nutrition Survey of the DPRK, Report by UNICEF, WFP and EU of a study undertaken in partnership with he government of the DPRK, November 1998 Draft report on the Multiple Indicator Cluster Survey in the DPRK 1998, UNICEF Pyongyang The treatment and prevention of malnutrition in the DPRK, Steve Collins, UNICEF Pyongyang, 7 September 1998 Interpretation and comments on the findings of the 1998 DPRK Nutrition Survey, Ray Yip, Senior advisor, Health and Nutrition, UNICEF China, undated Social Statistics DPRK, UNICEF Pyongyang, undated but 1999 Report on DPRK nutrition programme, Werner Schultink, Senior Adviser Nutrition section, UNICEF New York, UNICEF, Pyongyang, October 1999 DPRK UNICEF supported essential drug project assessment, UNICEF Pyongyang, November 1999 An update on UNICEF operations in the DPRK, weekly bulletin, UNICEF Pyongyang, various dates WFP Food and Nutrition Assessment of the DPRK March/April 1996, Lola Nathanail SCF seconded to WFP Pyongyang WHO WHO/UNICEF joint report on vaccine preventable diseases Jab-Dec 1998 in DPRK, Pyongyang, 27 May 1999 Perspectives for Health and Nutritional Support in DPRK, report on workshop September 1999, WHO Pyongyang Books Marcus Noland (ed), Economic Integration of the Korean Peninsula, Special Report 10, (Washington DC: Institute for International Economics, January 1998 Pang, Hwan Ju, Korean Review, (Pyongyang: Foreign Languages Publishing House, 1987) Han S. Park (ed), North Korea: Ideology, Politics, Economy, (Englewood Cliffs, New Jersey: Prentice Hall, 1996) Hazel Smith et al (eds), North Korea in the New World Order, (London: Macmillan, 1996) Interviews Representatives of ACF

Children’s Aid Direct Concern Worldwide Oxfam UNICEF WFP WHO

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