With a suspected coronavirus case load nearing 2 million, next to no vaccines, sparse medical infrastructure and limited ties to the global health community, North Korea, which has long shunned outside help, appears to be on the cusp of a crisis.
Over the past two years, as the pandemic raged around the world, North Korea refused multiple coronavirus vaccine offers. Instead, the country, already hermetic by choice and isolated by sanctions, closed its borders in a bid to maintain a “zero covid” approach.
The approach failed. Experts warn that the country’s covid death toll could top 100,000, with the North Korean population of 25 million providing fertile ground for new variants.
By most accounts close to entirely unvaccinated, North Korea faces incredible risks from the fast-spreading BA.2 subvariant of omicron identified in the country. While vaccines may have helped prevent a crisis of this scale, they cannot be administered quickly and widely enough to stop it once it begins.
Joshua Pollack, a senior research associate at the Middlebury Institute of International Studies at Monterey and co-author of a December paper that called for the immediate supply of pandemic aid to North Korea, said it “appears to be too late for a mass vaccination campaign to soften the blow from omicron.”
Instead, Pollack and his co-author Ferenc Dalnoki-Veress told The Washington Post, the United States and other nations need to focus on getting other supplies to North Korea — including antiviral drugs such as the Pfizer-produced Paxlovid.
“Show them that the American public cares what happens to the people of North Korea regardless of what the regime says,” Dalnoki-Veress, a scientist-in-residence at Middlebury College, said in an email.
“There’s no good option,” said J. Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies. “But there are things that can be done that can begin to ameliorate some of the worse consequences if they’re done quickly.”
North Korea’s pattern of rejecting aid — as well as its recent missile launches ahead of an upcoming visit to the region by President Biden — complicates attempts to supply the country. White House national security adviser Jake Sullivan warned Wednesday of the possibility of a nuclear test, a missile test or both around the trip to South Korea and Japan.
Last year, Pyongyang was offered shipments of AstraZeneca vaccines by Covax, the World Health Organization-backed program for getting vaccine doses to countries that wouldn’t otherwise afford them. A spokesperson for Gavi, the nonprofit that procures and distributes vaccines for Covax, said that “no formal requests” for coronavirus vaccines or other aid have been received from North Korea.
Bilateral requests have also been refused. A South Korean official said Thursday that, for the third day in a row, North Korean officials have given no indication of whether they would accept an offer of aid from Seoul.
A senior U.S. administration official said that the United States has no plan to share vaccines with North Korea, though 1 billion Pfizer doses that Washington had purchased for Covax could be used if the organization wished and received a green light.
The official, speaking on the condition of anonymity because of government rules, added that North Korea was “continuing to exploit its own citizens and divert resources from the country’s people to build up its unlawful nuclear and ballistic weapons programs” while rejecting offers of aid.
One of the only countries that North Korea might accept help from is neighboring China. South Korean media reported this week that flights had resumed between China and North Korea for the first time in two years, probably carrying emergency supplies.
Speaking at a news conference in Geneva on Tuesday, WHO emergency chief Mike Ryan said the body “has no special powers to intervene” and called on neighboring countries to help.
A major outbreak in North Korea could be as bad or worse, in terms of deaths, as the first wave that hit the United States and Europe in the spring of 2020.
“If it’s already reached one and a half million cases in, what, a couple of weeks? It’ll double every week — more than double every week — unless you have mitigation events and try to clamp down,” said John P. Moore, a professor of microbiology and immunology at Cornell University’s Weill Cornell Medicine.
William Hanage, co-director of the Center for Communicable Disease Dynamics at the Harvard T.H. Chan School of Public Health, said that firm estimates for the numbers of deaths per cases for BA.2 had not been fully established but appeared to be close to the ancestral virus that first struck in 2020.
That was about 0.5 percent — suggesting the death toll in North Korea could reach 125,000.
Hanage cautioned that there were numerous factors that could influence the case fatality rate. North Korea’s relatively young population, which has a median age of about 35, would probably be less likely to experience serious illness and death than older populations.
But many other factors are not in North Korea’s favor, according to Morrison.
“They don’t have vaccines. They don’t have any antivirals. They don’t have [personal protective equipment] and oxygen,” he said. “They’re not going to be able to protect their health workers. They don’t have ICU beds. They don’t have testing capacity or surveillance systems. They had extremely high malnutrition even before covid.”
“And then you’ve got the two-year border closing that has led to the depletion of any kind of supply chain into medical stockpiles,” he added. “It’s staggering.”
Hanage said that an out-of-control outbreak could lead to deaths in excess of the standard case fatality rate. “A complete loss of control will likely have some serious knock-on impact on health care,” Hanage said. “People will end up dying who otherwise would have recovered.”
The uncontrolled spread of BA.2 in North Korea could also lead to new variants, a risk that could reach beyond North Korean borders.
It is not clear why North Korea refused previous vaccine offers. Some analysts have pointed to national pride or the belief that imported aid could help spread the vaccines. Others suggest that North Korea was holding out for highly effective mRNA vaccines, such as those made by Pfizer, though they do not have the ultracold storage network required for a mass vaccination program using those shots.
Some hope that aid from the United States or other Western countries could lead to improved relations in other areas, but Dalnoki-Veress warned that explicitly tying help to another aim could backfire.
“In the end, the regime will decide when to open up,” he said. “It is critical to have conditions in place to be able to move as quickly as possible when they do.”