The Asia-Pacific Journal | Japan Focus Volume 14 | Issue 11 | Number 3 | Article ID 4897 | Jun 01, 2016

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The Emergence of an Informal Health-Care Sector in NorthKorea

Eun Jeong Soh

INTRODUCTION

Although health care in North Korea hasremained a major area of humanitarian concernfor outside observers, important aspects of thehealth-care system have gone unnoticed.Reports (Amnesty International 2010;Huffington Post 2013; Watts 2003) havefocused on the population’s nutritional statusand the dire condition of health-care facilities.In assessing a nation’s health status, the WorldHealth Organization (2009) pays attention tocertain indicators and the specific areas forimprovement that it has targeted. In contrast,there has been little discussion of daily health-care practices in North Korea, which remainlargely hidden because they take place outsideof the formal system. Where do people turnfirst when their children fall ill?

Despite evidence of the degeneration of itshealth facilities since the famine of 1994-98,North Korea has continued to claim that it ismaintaining its socialist health-care system.WHO, which has channeled assistance throughstate health-care facilities and collaboratedwith the Ministry of Public Health, has noted asubsequent revitalization and normalization ofthe health-care system, especially in the arenaof preventive health (WHO 2009). At the sametime, the country’s health sector has been noexception to the ‘bottom-up’ marketizationprocess that has continued since the economiccrisis of the 1990s. Although illegal, buyingmedic ine on the open market i s nowwidespread in North Korea. Private pharmaciesare evident on the streets of major cities. Thissituation elicits some important questions. Howdo people navigate a health system that

combines official adherence to socialistm e d i c i n e w i t h c o n t i n u i n g m a r k e tencroachment? What are the implications ofthis transition for North Korea’s health system?

This article examines the emergence ofinformal health-care practices in North Korea,practices that exist alongside and areinfluenced by the norms and habits of the past.Based on first-hand accounts of physicians andtheir coping strategies, private medicinesellers, and home-practicing doctors, itdescribes how health workers and patientshave coped with the decline of the hospitalsystem, the strategies and relationships theyhave developed, and the factors that haveenabled the emergence of new practices amidstthe decline of the old health-care regime. Itthen considers the consequences of thesechanges for health-care, as well as theirbroader implications for the country’s social,political, and economic systems. I argue thattraditional norms and practices have in turnbecome the basis for the emergence of newnorms and practices in the health arena.

One major finding is that the emergence of aninformal health-care space does not necessarilyconflict with, but rather complements, theformal sector. The resilience of North Korea’sformal sector, comprising multiple levels ofhospital facilities and a nation-wide medicalsupply system, is partly due to the expansion ofinformal networks which supply monetary andmaterial resources to the formal sector.Although little is known about the current stateof North Korea’s health care system, theevidence suggests that the formal sectorcontinues to function alongside invisible

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networks of informal practices.

To gather material for the study, I conductedtwenty-six in-depth interviews in 2013 withNorth Koreans who had resettled in the South.While there are valid concerns about usingdefector interviews as evidence for socialchange in North Korea (Joo 2014; Jung andDalton 2006, 774; Lankov and Kim 2008, 53),narratives about everyday life practices are lesslikely to be influenced by the defectionexperience than respondents’ views on politicalmatters. The interviews sought to elicitaccounts of practices, choices and interactionsrelating to health care as well as interviewees’opinions on the subject. Nineteen individuals,including two doctors and three pharmacists,described their experiences of health care inNorth Korea. Interviewees with particularlyrich stories to offer were interviewed morethan once. A number of former health workers,including two doctors, two pharmacists and onelocal health administrator, were particularlyinformative about how the formal system andinformal networks functioned. The participantswere diverse in terms of occupation,socioeconomic status, age, and date ofdeparture from North Korea. The testimoniesfrom those who left North Korea 10 to 15 yearsago describe situations and practices that arenow considered out of date; however, they areincluded here as they help provide anevolutionary picture of the process of socialchange. Most of the interviewees were from thenorthern regions of North Hamkgyung Provinceand Ryanggang Province, reflecting the generalmake-up of the North Korean refugeepopulation in South Korea. Thus the studycontains an inevitable bias toward the situationin these provinces. Three informants, however,were from Hamhung, South HamkyungProvince, and their experiences and accountscorroborate those from the northern provinces.In addition to this first round of interviews, twofurther rounds of interviews were conducted tosupplement and confirm the initial findings. In2014, I conducted interviews with ten Diaspora

Koreans residing in Northern China whofrequently travel to North Korea to supporthospitals and orphanages. Another round ofsupplementary interviews with fifteen NorthKorean refugees in South Korea took place inMay 2015.

I began by asking the participants to provide abrief personal oral history, which I followedwith questions about their experiences ofhealth care. The first question was: “What didyou do when you were ill or when your childrenwere ill?” The participants also played animportant role in shaping the subcategories ofmy inquiry. In several initial interviews, sellingmedicine, home-practicing doctors, andinformal payments were recurring themes. Ithen formulated more specific questions to gainfurther information about these activities. Inparticular, the interviews sought informationabout the networks, mechanisms, andpsychology of informal health-care practicesfrom the perspective of both providers andrecipients, in an effort to understand thefactors that enabled such practices to emergein the first place.

Table 1] The First Round of Interviewees

Age Gender Home province Occupation in North Korea Date ofdeparture

1 29 M N. Hamgyung Student 20062 75 F N. Hamgyung Factory worker 19993 48 F N. Hamgyung Doctor 19984 28 F N. Hamgyung Student 19975 44 F Ryanggang Pharmacist 20086 78 F Ryanggang Housewife 19977 80 F Ryanggang Pharmacist 20088 47 M S. Hamgyung Teacher 20129 45 F S. Hamgyung Farmer/Housewife 201210 73 F N. Hamgyung Farmer/Housewife 200611 46 F N. Hamgyung Doctor 200812 35 M N. Pyongan Military 201213 32 F N. Hamgyung Farmer 201214 60 M N. Hamgyung School official 199815 47 M S. Hwanghae Police 2008

16 68 M N. Hamgyung Retired factory official/trader 2006

17 47 F Ryanggang Housewife/ marketentrepreneur 2012

18 55 M S. Hamgyung Pharmacist 2012

19 40 M N. Hamgyung Accountant for local drug-supply office 2013

BACKGROUND

Free health care has been a major pillar ofNorth Korean socialism from the founding of

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the country in 1948. With assistance from theSoviet Union and other allies, the North Koreanauthorities strove to establish a free andcomprehensive health-care system, even asearly as the Provisional People’s Committeeperiod (1945-1948). With limited resources,much of the resources devoted to health care inthis formative period focused on preventivemedicine, and this is still an importantemphasis today. The revolutionary rhetoric ofthis period emphasized the notion of health asliberation, an abrupt departure from thecolonial health-care system that was seen asineffective for the masses and only benefitedthe ruling elites and the colonial authorities(Hwang and Kim 2007; Hwang 2006, 7). Bycontrast, the health-care policies formulatedimmediately after liberation placed theemphasis on free and universal accessibility. Torealize their ideal of universal free health carewith limited resources, the leaders of the newstate stressed the value of preventive medicineand mobilized mass participation in health andhygiene campaigns (Hwang and Kim 2007).

Along with this new conception of health ascentral to the socialist revolution, the fledglingstate also regarded health care as an importantpart of national security (Hwang 2006; Smith,2005). During the Korean War, death andillness caused by disease threatened nationalsecurity as much as battle casualties (Hwang2006, 45). This emphasis on health care wasrealized through building hospitals at all levelso f admin i s t ra t i on as we l l a s ma jo rpharmaceutical production facilities, witheducation, technology, and equipment providedin the 1950s by the Soviet Union, Poland,Czechoslovakia, Romania, Bulgaria, andHungary (Hwang 2006, 60–61). Aid fromsocialist states was also crucial to thedevelopment of medical education. Between1960 and 1964, the number of doctors(including physician assistants or “assistantdoctors”) in North Korea doubled from 11,919to 22,706 (Park, Kim, and Hwang 2003, 8). Therapid establishment of the health-care system

was also stimulated by ‘regime competition’with South Korea. The conception of health interms of national security recurred in the1990s when the economic crisis and theensuing famine led to widespread epidemicsand a virtual collapse of the state health-caresystem (Smith 2005).

If Soviet influence and aid shaped NorthKorea’s health-care system in its formativeperiod, a distinctively indigenous socialisthealth-care system emerged in the early 1960s.During this period, the state moved towardsbecoming a “unitary-Suryong regime” based onthe supreme authority of a single leader andthe promotion of juche ideology (self-reliance).An emphasis on the development and utilizationof Korean traditional medicine was also evidentduring this period, being compatible with thestate ideology of self-reliance.

Two schemes which demonstrate the nature ofNorth Korea’s highly mobilized socialist health-care system were the Jeongsung (dedication)movement and the doctor-designated districtsystem, both introduced in the early 1960s andstill in place today. Both policies fostered aclose relationship between health workers andlocal people by internalizing a sense ofdedication towards patients on the part ofhealth workers and encouraging a sense oftrust by patients in health workers. At the sametime, both health providers and patientslearned to find ways of circumventing the rulesfor their own convenience in everyday practice.

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Above: “Health care workers workselflessly”

Below: “Let us further increase thesuperiority of the socialist health caresystem”

The Jeongsung movement, begun in June 1961,was a Stakhanovite-type campaign in which thegovernment lauded a chosen health worker’sselfless dedication for their patients andinitiated a nationwide system on this model.The movement also sought to sweep away thesense of superiority traditionally felt by healthprofessionals over their patients and integratethem into society as equal workers andneighbors (Ch’oe, Kim, and Hwang 2006).Under this system, public recognition andcareer advancement were the most valuedincentives for health workers.

Ms Lee was a pharmacist who graduated fromthe prestigious Pyongyang University MedicalSchool. Because of her privileged familybackground, however, she was posted to ahospital in North Korea’s most remoteprovince, Ryanggangdo. She was aware thatthe only way to make amends for her familybackground was to prove her dedicationthrough diligent effort at the hospital, and bybecoming a member of the Party. Armed withboth a strong sense of dedication anddetermination for career advancement, when

she did not have enough lab rabbits to test adrug that she developed, she injected herselfwith the serum, causing an outbreak ofjaundice.1 On a number of occasions shedonated skin grafts to patients with burns(Interview, J. Lee, November 20, 2013). Healthworkers considered such acts of dedication apersonal duty that was rightly demanded ofthem (Hwang 2006). Ms Lee even postponedher marriage as a mark of dedication to her joband the party. She was thus able to become aParty member and receive promotion withinthe hospital system. Professional advancementand communal recognition, however, couldfunction as incentives for such exemplarydedication only when the system was able toguarantee economic secur i ty . Suchunconditional commitment displayed by thenation’s health workers fell away as the statecould no longer guarantee a stable income.

A second policy that shaped the doctor–patientrelationship was the doctor-designated districtsystem. The scheme was introduced in alladministrative units – cities, counties anddistricts – in 1969 and was strengthened in1980. A single doctor was made responsible forthe general heal th of 5 -8 inminbans(neighbourhood units of 1200 to 1500 people)by implementing public health campaigns,education and hygiene projects. If theJeongsung movement as a form of ideologicalmobilization encouraged health workers tosacrifice for their patients, the household-doctor system formed a close bond betweendoctors and patients through obligatoryhousehold visits, educating residents abouthealth and hygiene, and conducting regularhealth checks in designated households (Ch’oe,Kim, and Hwang 2006, 29). The systemresembled that in place in the Soviet Union,which emphasized the role of preventivemedicine (Lee 2008, 27). Through thisgrassroots network, it was thought thatpreventive health care could be effectivelyimplemented. Particularly given limitedresources, the emphasis on preventive

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medicine and traditional medicine made sense.

One outcome of the household-doctor systemwas that doctor–patient relations became closeand often personal, allowing patients to seekassistance outside of the formal health-caresystem. Former doctors who had worked in thesystem told me that patients often came totheir home after hours to avoid long queues inthe hospital and see the doctor of their choice(Interview, J. Kim, October 5, 2013; Interview,S. Hahn, October 5, 2013). Patients alsoutilized personal networks when it came toseeking advanced health services (Interview, D.Kim, December 10, 2014), seeking out skilleddoctors through word of mouth and personalconnections (Interview, S. Hwang, December10 2013). It was also possible to obtain medicalnotes from health workers with whom theywere acquainted in return for a small token ofappreciation (Interview, D. Kim, December 10,2014).

Whether it is a remnant of traditional culture orthe natural authority associated with healers,health workers in North Korea have alwaysenjoyed the respect of their fellow citizens andhave an occupation with relative security.Regardless of the state’s relegation of healthworkers to a level equivalent to ordinarylaborers, they were in general well-respectedand took pride in their profession. Aselsewhere, doctors in North Korea enjoyed adegree of social prestige. One interviewee toldme that when she became a doctor in her earlytwenties, her patients occasionally broughtgifts to her house, and her mother was proudthat she received such respect (J. Kim, October5, 2013). While limited in incentives comparedwith a political career, for North Koreans a jobas a health worker was relatively secure,prestigious and intellectually challenging. Forthis reason, for those whose family background(sŏngbun)2 did not allow them to pursue aprestigious political career, medicine was theprimary choice of occupation. For instance,many children of Korean returnees from Japan3

chose to pursue medicine: not only did theyhave a preconceived perception of a medicalcareer as an honorable path, but they alsoanticipated that it would be a relatively secureway of managing their lives (D. Kim, December10, 2013).

Pyongyang Maternity Hospital

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By the mid-1990s, a discrepancy had arisenbetween the health-care goals of the statesocialist system and the reality of what NorthKorea’s formal health-care institutions couldprovide for ordinary citizens. With the state’sinability to supply basic medicine, electricityand reliable salaries for workers, hospitalsbecame unable to treat patients adequately.The free state health-care system virtuallyceased to function at all levels, with primarycare especially hard hit (Linton 2010). Healthworkers, lacking food rations and income, weresuddenly forced to find alternative ways ofmaking a living. This situation encouragedthem to negotiate a move away from theworkp lace t o seek o ther economicopportunities, just as many other state-sectorworkers did during the period when thenational food distribution system ceased tofunction.4 As malnutrition and the spread ofcommunicable diseases increased the demandfor health care, the state authorities sought toclamp down on absenteeism by health workers.At the same time, with the limited services thathospitals and clinics could provide, patients’expectations, levels of trust and reliance on theformal health-care system deteriorated.

The degradation of the nation’s healthinfrastructure, a lack of transportationservices, and unreliable electricity and watersupplies all remain obstacles to accessing good-quality health care in North Korea. Thissituation was graphically portrayed in anAmnesty International report published in 2010(Amnesty International 2010). Chronicmalnutrition, stunted growth in children,widespread tuberculosis and a lack oftreatment for incommunicable diseases allremain serious concerns. Demand for medicalservices is high due to the persistently highmalnutrition rate and consequent exposure toboth communicable and incommunicablediseases. Paradoxically, however, according toofficial WHO figures, North Korea has a lowerchild mortal ity rate, higher levels ofimmunization and maternal care access, and a

higher number of health workers than theregional average for Southeast Asia (WHO2009; WHO 2014).5 According to WHO, thissituation has come about as a result of NorthKoreans’ high level of health awareness and themaintenance of an extensive health-careinfrastructure through which WHO assistanceis channeled (WHO 2009).

The North Korean government has emphasizedits intention to maintain a free and socializedhealth sector. As a result, despite lacking theresources to provide for the country’s over 700hospitals, 6000 clinics and 300,000 healthworkers, privatization and decentralization inthe health-care sector have apparently beenminimal. While there are reports of privatelyowned and financed pharmacies operating inthe streets of major cities and even in a numberof hospitals (Choǔnbǒttǔl 2007), health workersand hospital managers are generally reluctantto seek outside resources directly andautonomously for fear of repercussions by thestate authorities. Nevertheless, under NorthKorea’s unique path of post-famine transition,informal health-care practices such as informalpayments, a black market for medicines, anddoctors practicing from private homes havedeveloped.

HEALTH WORKERS TAKE TO SELLINGMEDICINES

During the period when the ration systemfailed, health workers generally remained attheir posts, cooperating with their co-workersin an attempt to cope with the shortage ofmedicines. Dr Kim, who worked in a children’sward at Chongjin City People’s Hospital, toldme that over a period of several months in1996, each doctor was given sufficient suppliesof penicillin to treat only two patients. If adoctor had ten patients requiring treatment,she had to make a strategic decision about theallocation of the drug, much like triage logic inmilitary hospitals during wartime. Dr Kimrecalls asking herself, “Should I give it to the

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patients with the most serious conditions? Butif they are going to die anyway, should I notgive it to others who have a greater chance ofsurvival?” Doctors rented and borrowedmedicines from each other in an effort to savetheir patients (Interview, J. Kim, October 5,2013). In their daily struggles with dyingpatients and economic hardship, however, fewquestioned the source of the problem: “No onereally questioned what was really wrong at thetime” (Interview, J. Kim, October 5, 2013).Interviews suggest that most accepted thestate’s reassurances to its citizens, includingphysicians, that the economic sanctions appliedby the US were the source of the nation’shardships.

Though Dr Kim struggled to feed her ownfamily, she told me that she dared not sell thescarce medicines to which she had access,seeing child patients dying in front of her everyday. As medicine from China became readilyavailable in North Korea thanks to smugglers,more health workers began trading in drugs.However, some health workers had toovercome serious misgivings before becominginvolved in informal activities of this kind. Ittook two years of persuasion by formerschoolmates before Ms Lee, a pharmacist,finally decided to get involved. A sense of guiltheld her back. She began the practice onlywhen contraband secured by her husband wasconfiscated by the police and she became thesole breadwinner for her family (Interview, Y.Lee, October 23, 2013). Another interviewee,also a pharmacist, never became involvedbecause she was aware that many medicinescirculating around that time – the late 1990sand early 2000s – were fake (Interview, J. Lee,November 20, 2013).

Normally, informally acquired medicines were(and still are) sold quietly under the counter inmarketplaces or in private homes. Throughword of mouth, patients know where to findeffective drugs. Over time, competition amongmedicine sellers and private “house doctors”

provided incentives for them to demonstratetheir credibility and so gain the trust of theirpatients. Because many dangerous counterfeitmedicines are still being imported from China,practitioners with the ability to provide safeand effective drugs are keenly sought after.Because of their expertise and credibility in thisarea, many retired doctors have taken toselling medicines in the marketplace.

As the informal health system developed,patients bought medicines in the localmarketplace (jangmadang) and brought themto their doctors to confirm that their purchaseswere safe to ingest or be injected. As the stateauthorities regulated the sale of medicines andforbade doctors from seeing patients at homeand selling drugs, innovative referral practices,employing existing networks of doctors andpharmacists, were developed to avoid theregulations. These networks also had the effectof mutual monitoring and enforcement ofexpertise and trust. The “utilization ofcommunity networks as social capital,”observed in previous studies of North Korea’sinformal economy (Chang 2004, 342), is alsoevident in the formation of supply networksinvolving medicines based on preexistingrelationships in which mutual obligations andtrust in each party’s expertise and competenceare embedded.

T H E E M E R G E N C E O F D O C T O R SPRACTICING FROM PRIVATE HOMES

The phenomenon of doctors practicingprivately out of their own homes also emergedin response to the emergency conditions of the1990s. While unregistered traditional healershad always existed their activities were notrecognised by the state health-care system (H.Lee, October 15, 2013). During the 1990s,people increasingly sought the help of theseinformal healers, aware that they could notaccess treatment from the hospital systemwithout money and personal connections. Thepractice of Korean traditional medicine by

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state-sanctioned health workers, regardless oftheir expertise, was already widespread thanksto the official emphasis on the twin use oftraditional and modern medicine. In theabsence of resources in the formal sector,patients demanded these services and healthworkers were eager to provide them, oftenusing personal networks and working insettings outside of the formal hospital andclinic environment. Over time, patients came toprefer private “house doctors” for reasons ofboth convenience and trust. Many respondentsdescribed North Korean hospitals as “empty,”adding that “nowadays, private house doctorsare more popular among the people”(Interviews: S. Hwang, October 25, 2013; M.Park, November 18, 2013; G. Kim, November10, 2013; Y. Lee, October 8, 2013).6

When a person is hospitalized in North Korea,the patient has to provide everything neededduring treatment: medicines, IV, blankets,firewood, and meals, not only for themselvesbut also for the staff responsible for their care.As a result, only those who can afford theseexpenses are admitted to hospital, and it hasconsequently become common for patients toopt for private house doctors over hospitaltreatment. Private doctors are often seen asmore trustworthy than hospital doctors, whohave less incentive to establish a reliablereputation and trusting relationships withpatients. In the earlier period of the 1990sfamine, unqualified home-practicing doctorswere responsible for high levels of medicalmisadventure. Despite attempts to concealtheir incompetence, such practices could not besustained for long, as reputation (spread byword of mouth) has always been the mostimportant factor making for a successfulpractice.

House doctors generally examine a patient’spulse, apply acupuncture treatments, and tellpatients where to find medicine sellers. Theseare functions of a primary doctor. Patients donot visit them with empty hands. For the

average citizen, remuneration in the form of agift could be anything from a bundle of noodlesto a packet of cigarettes. In Musan, NorthHamgyong Province, there was a set monetarypayment for seeing a home-practicing doctor ofbetween 30 and 40 thousand won (equivalentto about 10 kg of corn) in 2013.

House doctors provide services that the statehealth care system struggles to provide –resources, expertise, and immediateaccessibility. Their success depends on thetrust built up with patients and word-of-mouthrecommendations. For instance, oneinterviewee who had worked as a farmer toldme about a doctor attached to her local jillyoso(primary-level clinic at a cooperative farm) in asmall town in Southern Hamkyong Province.Because her treatment (both diagnosis andprescription) is regarded as competent andeffective, many residents prefer to see her overother doctors working at the clinic. Jillyosodoctors regularly receive patients at home afterworking hours, but because selling medicinesfrom private homes is prohibited, she refers herpatients to another private house wheremedicines are sold – incidentally illustrating themutually beneficial relationships enjoyed byprivate pracititioners. This particular doctoralso has a mutually beneficial relationship witha police officer; she provides him with freemedical assistance and he protects her fromany official repercussions that her activitiesmight incur. Although she was once sackedfrom the j i l lyoso and was ordered to“revolutionize herself” (by laboring on acooperative farm for three years) for her illicitmedical practices, she continued to seepatients as they sought her care. As a result,the jillyoso lost face and were forced to readmither to the practice, and the authoritiescancelled her sentence (G. Joo, November 10,2013; B. Cha, November 10, 2013).

The key factors that determine a house doctor’ssuccess are possession of a practicing license,work experience, sincerity, and personal

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recommendation. Many home-practicingdoctors are retired medical practitioners. Witha background of experience of working in thehospital system and acquiring specialistknowledge and good reputations, they are in abetter position to gain their patients’ trust.People tend to trust retired doctors, who aregenerally considered to have had a soundmedical education along with a good deal ofexperience, at the expense of younger doctorseducated during or after the period of thefamine and the more general breakdown ofsocietal systems in North Korea (Interview, S.Hwang, October 25, 2013). Qualificationsgained in the past and a career begun when theformal health system was functioning alsomatter to North Koreans. Even though the freehealth-care system provided by the state istoday only a shadow of its former self, itslegacy is still important for the doctor–patientrelationship in the 21st century.

MAINTENANCE OF THE FORMAL SECTOR

For doctors of working age, there are manypractical reasons for them and other healthworkers to remain in the hospital system ratherthan to receive patients in their private homes.Indeed, whether it is even possible for doctorsof working age (up to 55 for women, 60 formen) to leave their hospital positions and seepatients at home was disputed by myinterviewees and varies according to region. Byseeing patients at the hospital, doctors havemore opportunities to visit them and receivegifts. However, while continuing to meet theirobligations in the hospital system, they aregenerally still able to receive patients at homeafter working hours. Thus, informal practicesdo not compete with the formal sector, butrather complement it.

Female health workers are especially wellplaced to benefit from their hospital roles, asopposed to working as housewives, as well asengaging in informal economic activities. WhenMs Lee, one pharmacist informant, got

married, she quit her job and became a full-time housewife. Before the 1990s economiccrisis, it was common for a married woman tobe a stay-at-home wife. Since the crisis,however, she was frequently mobilized forpublic works projects, ranging from roadbuilding to farming. Thus, it was much harderwork being a member of her local inminbanthan working in a hospital. In the mid-2000s,Ms Lee went back to work at a hospitalpharmacy. By belonging to the hospital staff,she was able to avoid the physically demandingpublic mobilizations required of inminbanmembers and had more spare time to earnsome extra income (Interview, Y. Lee, October23, 2013). Thus, by strategically rejoining theformal institution, Ms Lee became freer toconduct informal health-care practices such asselling medicine and seeing patients privately.Ms Lee’s strategic choice to maintain heraffiliation with the hospital system whileengaging in these informal practicesdemonstrates why state institutions continue tofunction in North Korea despite the rise ofinformal alternatives.

Over time, North Korean hospitals, forced toself-manage in the absence of the centralstate’s provision of medicines and othersupplies, have accepted the role of privatepharmacies and informal payments. Though itmay not be possible for hospitals to negotiateindividually to acquire medicines from foreigndonors, buying drugs and other necessarysupplies from China is sometimes an option (Y.Lee, October 8, 2013). One semi-privatisedhospital pharmacy is managed by a privatedealer who procures medicines, sells them onsite, and pays a portion of his income to thehospital. In this way, the hospital both meets itsneed for medicines and makes some profit thatgoes towards meeting its expenses (Y. Lee,October 23, 2013).7 Thanks to such informalarrangements, the collapse of the state-runhospital system has been avoided. Hospitalscontinue to function as places where patientsreceive diagnoses, possibly for free, and where

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doctors and patients meet and establishrelationships. Some interviewees affirmed thatmedical care is available free of cost foremergency patients (e.g. M. Park, November18, 2013). Interviewees recognized that, inparticular, hospitals are places where patientsgo to receive a diagnosis, especially when thereis a need for diagnostic equipment like x-raymachines. Officially, diagnoses are stillprovided for free, although there is anexpectation that patients will offer doctors apacket of cigarettes or similar items to showtheir appreciation (Interview, Y. Lee, November18, 2013).

However, the biggest obstacle to reviving theformal health sector is growing mistrust and alack of expectation from patients. Economicpower and personal networks have becomeessential for accessing the resources of theformal health-care system. As a result, whilethe formal sector continues to be maintained, ithas a reduced role to play. North Korea’s oncefree and comprehensive health-care system hashad the effect of marginalizing ordinarycitizens and especially the poor.

THE ETHICS OF INFORMAL HEALTHCARE

The “moral economy” of a given society hasbeen described in terms of a popular consensuson “what distinguishes legitimate fromillegitimate practices” (Arnold 2001, 93). Sucha consensus is rooted in a society’s traditionalnorms and practices and is “capable ofinspiring action” (Arnold 2001, 89). Is there apopular moral consensus in North Korea onhealth care? If so, is it rooted in valuesembedded in and fostered by the health-careinstitutions of the nation’s past, or does itreflect a newly emerging set of market-basedvalues? And does any such consensus extend toinformal health-care practices?

One possible answer can be found in thesurprising reaction of North Korean defectorsto their experiences of South Korean hospitals.

Despite witnessing and benefiting fromtechnological advancement and the highfunding levels enjoyed by hospitals in theSouth, many were somewhat dissatisfied withthe impersonal and capitalistic character of thehealth-care system in their new home. Theseinterviewees frequently expressed theirnostalgia for the social ist ideals andhumanitarian attitudes that they hadexperienced in North Korean hospitals. In part,this phenomenon reveals the common humantendency to reflect on one’s past experienceswhen evaluating new situations. Supportingthese anecdotal observations, I suggest that thenew in forma l prac t i ces , ne tworks ,relationships, and expectations that haveemerged in North Korea since the 1990s arerooted in the norms and incentives fostered bythe earlier, socialist health-care system:intimate doctor–patient relationships based ona reciprocity involving dedication and trust,and the moral economy of a free health-careregime.

Close relationships between doctors andpatients were fostered under the state’s moralinjunction that health workers ought to beselflessly dedicated to their patients. Thestate’s inculcation of such values in health-careworkers had the effect of blurring the linebetween private and public spaces fortreatment, with the consequence that visitingdoctors at home was not perceived as a strangeor new practice for patients. As mentionedabove, even when the formal system wasfunctioning well, patients sometimes visiteddoctors’ homes when circumstances allowed,bringing a small gift as a show of appreciation,in order to avoid long waits and to see thephysician of their choice. Though doctors mightbe irritated by such visits, the selfless devotionto patients’ needs internalized by statepropaganda campaigns compelled them toreceive patients at home, albeit oftenreluctantly. The “home doctors” who emergedin the post-famine period were seen as alegitimate continuation of such interactions

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beyond the spaces of hospitals and clinics, inboth the minds of health workers and patients.These normalized interactions outside of formalhealth-care institutions acted to reinforcehealth workers’ expertise and credibility in thepublic eye, even when practicing medicineoutside of formal settings. Several intervieweeswere happy to categorize jangmadang medicinesellers and home-practicing doctors as health-care workers, thus ensuring that their expertisecould be trusted.

Despite a clear recognition of the illegal statusof such practices, my interviewees registered aquiet and reluctant approval of the informalactivities of medicine sellers and home doctors.Their reasons were economic: “They have tofeed their families as well” (Y. Lee, October 8,2013). Many interviewees thought that retireddoctors should be entitled to some form ofincome in the absence of the state provision ofwelfare for retirees. This practice is alsojustified because doctors in North Korea enjoyliving standards equivalent to those of ordinaryworkers, notwithstanding the sense of privilegeassociated with the profession. This “economicsubsistence” argument is used to justify thewidespread existence of what are called “non-legal activities” in North Korea, activities thatare legally prohibited but de facto (orcustomarily) permitted (Cho et al. 2008, 168).“Loyalty to the Party” or “achieving socialism”must give way to such immediate concerns.

My informants agreed that the state shouldprovide health care and, when it cannot, itloses the moral authority to regulate “anti-socialist” activities that nonetheless amelioratethe harsh conditions of life faced by manypeople in North Korea. As long as they do notharm anyone, such informal activities helpresidents and provide comfort in times ofhardship, and therefore should not beregulated. “They are doing what the countrycannot do for us. So why should such practicesbe regulated? What they do indeed saves lives.”On the other hand, interviewees expressed

moral indignation towards bogus doctors andmedicine sellers who endanger trustingpatients’ lives (Y. Lee, October 8, 2013).

Contrary to the general approval forjangmadang medicine sellers and homedoctors, there was a shared criticism of certaininformal practices prevalent in the formalsector. Interviewees expressed contempt forhealth workers or hospital administrators whohoard medicines. Mrs Cha (December 20,2013) described how doctors and hospitalpharmacists make out bulk prescriptions fordrugs donated by the UN, but instead of givingthem to patients, they sell them to privatemedicine dealers. In describing this informalhoarding system, she conveyed the sense ofinjustice she feels about what the system hasbecome, even though, in times of personalneed, she had herself acquired drugs directlyfrom the hospital.

How is such shared moral outrage expressedand communicated to the bureaucrats chargedwith enforcing the regulations? Dissatisfactioncan be expressed verbally as a way ofconfronting local officials directly. Intervieweesargued that in order to survive in North Korea,one often has to take a firm line and defendone’s position logically in order to persuadeofficials of the merits of one’s case. While thismight seem surprising given the state’s tightcontrol over its citizens, the expression ofcomplaints to local officials is facilitated bypreexisting relationships between officials andcomplainants formed through family networks,neighborhood relations, friendships, a sharedhistory as classmates, and so forth. Socialrelations in small regional cities in North Koreaare close, shaped by cultural traditions,socialism, and communalism, and reinforced bythe coping and survival strategies developed toweather times of hardship.

However, given the nature of a regime thatdoes not accommodate dissent, the expressionof dissatisfaction generally takes non-verbal

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forms. One term that cropped up frequentlywas “disaffection” (panbal). In the narrativesrecorded in this study, panbal refers to feelingsas well as expressions of disaffection againstthe authorities (normally local officials chargedwith regulating anti-socialist activities), as wellas with life in general. Although the authoritiesare well aware of such disaffection in thepopulace, Ms Hahn expressed her opinion thatin reality the government lacked the power toimpose its own regulations: “If the authoritiesregulate even those activities, there would betoo much disruption” (Interview, S. Hahn,October 26, 2013). According to a former policeofficer, “a police officer will be unpopular if hetakes unnecessary enforcement action”(Interview, M. Park, November 18, 2013). Ifcomplaints against local officials accumulate,they will damage their reputation withresidents. In E. P. Thompson’s words, referringto the 18 th-century English crowd, “theauthorities were, in some measure, theprisoners of the people” (Thompson 1971, 88).

From the point of view of local officials, theexistence of these informal coping networksand strategies are to be applauded, asalternative ways of providing health care mayhave the effect of allaying complaints byresidents. Local officials also have privateincentives to turn a blind eye to such informalactivities. Normally, these private practicesoperate with the help of local police who acceptbribes from practitioners. More importantly,police officers also draw on the services andexpertise of informal health-care workers fortheir own families’ survival and wellbeing. As aresult, local officials and residents have cometo share similar views on these extra-judicialactivities. Thus the convergence of preferencesamong providers, consumers, and regulatorshas contributed to the emergence of an activeand evolving informal health-care sector inNorth Korea.

CONCLUSION

This article has presented and analyzed anevolutionary view of the emergence of aninformal health-care space in North Korea. Theemergence of new health-care practices inNorth Korea was triggered by the incapacity ofthe formal health-care system to supplyresources during the ongoing health crisis ofthe 1990s and later. These practices areshaped by existing norms of fairness,interpersonal networks and habits fosteredunder the state-led health-care system, as wellas newly introduced norms relating to trust,expertise and rewards. This space has emergedwithout significant changes in the formalinstitution, and in fact complements it.However, the role and influence of the formalsector have shrunk as the power dynamics ofmonetary payments and interpersonal networkshave reduced its footprint. As a result, thespace occupied by the formal sector has beenreduced, while the informal sector continues toexpand its zone of influence. The new norms ofpayment for services and the utilization ofpersonal relationships in the formal sector areregarded as unjust at the same time that thesepractices are considered inevitable, necessary,and even efficient. The new norms adopted inthe formal sector have contributed to thecreation of an informal health-care space, whilethe role and influence of the formal sector havedwindled.

Three main conclusions are offered based onthis preliminary study of the informal healthcare sector in North Korea. (1) The emergenceof an informal sector complementing the state-controlled formal sector will not necessarilyresult in the collapse of the latter, as the twoare interlinked by actors’ incentives to engagein both sectors, by the sharing of resources thatflow in both directions, and by the division ofroles between the two sectors. (2) It alsoimplies a possible shift of social norms – theconcept of fairness and justice in health care –from the formal to the informal sector, as theformal sector is affected by encroaching marketinfluences. (3) While this study suggests that

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the informal sector is accommodating existingsocial concepts of morality and fairness inhealth care, this premise needs to be furthertested in more systematic studies. It is too soonto conclude that the informal sector is moreaccessible to ordinary citizens and the poor. Itmay rather be that adequate health care isequally inaccessible to the poor not only in theformal sector but also in the and informalsector, where the logic of money and privilegedrelationships operate.

However these questions may finally beanswered, the development of informal health-care practices in North Korea since the 1990sdoes not mark the demise of the formalsocialist health-care system. In fact, this papersuggests that the informal sector hascontributed to the resilience of the formalsector. While the complete dominance of thestate-provided health system is a thing of thepast, the emergence of an informal health-caresector has paradoxically facilitated the survivalof the socialist system. The dynamics ofinteraction between the two sectors helps to fillout the broader picture of “muddling through”that is such a marked characteristic of thesocialist state of North Korea.

The research on which this article is basedarose out of the ARC Laureate Project ‘InformalLife Politics in the Remaking of NortheastAsia,’ funded by the Australian ResearchCouncil.

The author would like to thank Simon Avenell,Gavan McCormack, and Tessa Morris-Suzukifor their valuable comments.

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Eun Jeong Soh participated in Tessa Morris-Suzuki’s Australian Research Council LaureateProject, Informal Life Politics, as a post-doctoral fellow (June 2013 - January 2016), at theSchool of Culture, History and Language, College of Asia and the Pacific, the AustralianNational University. She currently resides in Seoul. Eunjeong.soh@gmail.com

Notes1 This story also indicates that, even in the 1970s, the development of new drugs in hospitalswas common in North Korea.2 Sŏngbun is a social classification system that divides the entire population into five majorgroups according to their families’ status and deeds during the Japanese colonial period andthe Korean War. One’s sŏngbun is an important, if not the only, factor determining prospectsfor higher education opportunity and career advancement: See Fyodor Tertitskiy, “Are youspecial, basic or complex? Behind North Korea’s caste system,” The Guardian (4 March2015).3 “Returnees” are 93,340 ethnic Koreans from Japan who returned to North Korea betweenDecember 1959 and July 1984. The repatriation took place on the largest scale in 1960 when49,000 individuals made this journey. Their children and grandchildren often seem to retainthis identity. See Tessa Morris-Suzuki, “Exodus to North Korea Revisited: Japan, North Korea,and the ICRC in the “Repatriation” of Ethnic Koreans from Japan,” The Asia-Pacific Journal 9,Issue 22, Number 2, May 24, 2011.4 This period is also referred to as “the March of Hardship,” the term used by the state torationalize the suffering that citizens endured in the 1990s. However, many North Koreans

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refer to it simply as the “non-ration period.”5 The Democratic People’s Republic of Korea (DPRK) country office comes under the umbrellaof WHO’s Southeast Asian Regional Office.6 These interviewees come from four different regions of the country.7 Similar practices involving the partial privatization of state-run businesses have beendocumented in other contexts (Lankov 2013, 85).