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Year : 2019  |  Volume : 22  |  Issue : 7  |  Page : 913-919

The perceptions and experiences of North Korean refugee doctors concerning the burden of non-communicable diseases in North Korea

1 Division of Family Medicine, Seoul National University Graduate School of Medicine, Seoul, South Korea
2 The Office of Medical Research and Academic Affairs, Korea University Medical Center; Association of Healthcare for Korean Unification, Seoul, South Korea

Date of Acceptance12-Mar-2019
Date of Web Publication11-Jul-2019

Correspondence Address:
Dr. S Ha
Association of Healthcare for Korean Unification, Seoul; 50-1 Yonsei-ro, Seodaemun-gu, Seoul - 03722
South Korea
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_494_18

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Background: Non-communicable diseases (NCDs) are a major challenge to health and social development in the 21st century, and North Korea is no exception. However, there is a lack of information concerning NCDs in North Korea, and a different approach is needed to understand the NCDs burden there. This study examines the perceptions and experiences of refugee doctors from North Korea concerning the NCDs burden in North Korea. Methods: Focus group discussions were conducted with 10 refugee doctors from North Korea who had been recruited through snowball sampling. Results: North Korean refugee doctors participating in this study indicated that NCDs are the highest priority diseases, that North Koreans did not appear to have a high level of understanding and knowledge of NCDs, that economic breakdown was the primary cause of the NCDs burden, and that a high priority should be assigned to targeting NCDs in North Korea. Discussion: Although the North Korean refugee doctors were medical professionals, they faced serious challenges accessing and managing patients with NCDs. South Korea needs to prepare for a potentially large number of people with NCDs should a freer movement of peoples occur between the two countries.

Keywords: Non-communicable disease, North Korea, qualitative research, refugee doctor

How to cite this article:
Choi H R, Ha S. The perceptions and experiences of North Korean refugee doctors concerning the burden of non-communicable diseases in North Korea. Niger J Clin Pract 2019;22:913-9

How to cite this URL:
Choi H R, Ha S. The perceptions and experiences of North Korean refugee doctors concerning the burden of non-communicable diseases in North Korea. Niger J Clin Pract [serial online] 2019 [cited 2020 Jul 5];22:913-9. Available from:

   Brief Introduction Top

This study investigated the views of 10 refugee doctors from North Korea to ascertain their perceptions and experiences concerning non-communicable diseases (NCDs) in North Korea. Given the possibility of a freer movement of peoples between North and South Korea, it is important to establish the extent of knowledge of North Korean doctors and greater awareness of how significant NCDs are in North Korea to help South Korea to prepare and respond effectively. (74 words).

   Introduction Top

Non-communicable diseases (NCDs) are a major challenge to health and social development in the 21st century, particularly in low- and middle-income countries (LMICs).[1] Of the causes of death worldwide, 68% are due to NCDs and 80% occur in LMICs. Moreover, the NCDs pattern in LMICs is expected to worsen dramatically,[2] including in North Korea. According to World Health Organization (WHO) and North Korean Ministry of Health data, NCDs form most of the disease burden in North Korea. The WHO (Pyongyang Office) identified NCDs as a major health challenge in North Korea, with 19% of deaths attributable to NCDs.[3]

However, the international community generally appears less interested in NCDs in North Korea.[4],[5],[6] This is likely due to a lack of information concerning NCDs in North Korea resulting from poverty, malnutrition, and infectious disease outbreaks caused through the collapse of social and medical systems in the mid-1990s.[7],[8],[9],[10],[11],[12],[13] Moreover, official announcements from the North Korean government and researchers regarding NCDs are difficult to obtain, as is evidence that the North Korean government is taking action on NCDs.

Undertaking research in North Korea with direct permission from the North Korean government is challenging, with access possible for only a few organizations and researchers. Mis-understandings and prejudices can be an issue, whereas an informed understanding of the burden of NCDs is very important for an appropriate response,[14],[15] but this has been difficult to obtain in North Korea.

The burden of NCDs in North Korea is scarcely known publicly, and it is possible that misconceptions exist there. Limitations in the international community's precise awareness of the current NCDs status in North Korea and difficulties in ascertaining more accurate information concerning the NCDs burden in North Korea mean that a different approach is required from that of previous studies to understand the current state more accurately.[16],[17]

Many studies have been conducted on experts from North Korea as a means of understanding the situation in North Korea. Specifically, one useful method found to understand the internal situation of North Korea is through engaging with North Korean defectors, given access to North Korea is difficult. Research has been undertaken using knowledge obtained from North Korean doctors to better understand the medical situation there. However, it does not appear that research has been conducted on NCDs in North Korea using knowledge obtained from North Korean doctors. Accordingly, this study explored the perceptions and experiences of refugee doctors from North Korea in relation NCDs in the North Korean population.

   Materials and Methods Top


This study drew on two phenomenological methodologies, the Colaizzi method and the van Manen method to interpret the lived experiences of North Korean refugee doctors who have experienced in North Korea.[18],[19],[20]


Ten North Korean refugee doctors living in South Korea were selected using snowball sampling. The number of participants may not be considered sufficient. However, according to the South Korean government, about 23,641 North Korean refugees came to South Korea from 2006 to 2017. However, the number of doctors does not exceed 100. In addition, only a few of them work as doctors in South Korea. The focus group discussions (FGDs) were conducted and reported for research services (yong-yeog-2-2014-7) approved by the foundation of South Korean government, Ministry of Health and Welfare. These North Korean refugee doctors consented to participate in the research [Table 1]. Participants were compensated for their participation.
Table 1: General characteristics of participants (n=10)

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Data collection

Data were collected through three FGDs between November 2013 and March 2014. All of the men and women participated in the FGD regardless of gender. Each FGD took approximately 2 hours. A laptop computer and a voice recorder were used to take notes and collect data. Discussions were conducted by the authors of this study. One of the researchers, a former North Korean refugee doctor who had acquired a medical license in South Korea, ensured thoroughness in questioning based on personal experience. Before the discussion, this researcher contacted the participants to explain the purpose and content of the study. The researchers developed their own questions based on the NCDs status in North Korea as identified through literature reviews, given the absence of reported research questions on the NCDs burden in North Korea. Additionally, other sources of information, including social networking sites, were used to supplement insufficient information, where required [Table 2]. The researchers determined the questions and revised and supplemented them with the help of a North Korean specialist with experience working at a North Korean university hospital. Subsequently, all the researchers reviewed and agreed on the final questions.
Table 2: Order of the focus group interview and topics

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The recorded data were organized into four steps involving transcription: understanding the data, contents categorization, and discussion. The researchers confirmed the authenticity of the recorded data. Identification and copying of the recorded material was undertaken while listening to the recorded contents and a complete transcription of the data was obtained.

The transcription was analyzed using Colaizzi's method for descriptive phenomenological data analysis, which involved categorizing the interview contents and analyzing meaning through repeatedly reading the sentences according to the subdivision method. Selective coding was used to analyze words, phrases, and sentences that were identified as particularly noticeable within the participant's statements to analyze the process and structure of the reported experiences and the content meaning. Holistic coding was used to combine the meaning, structure, and process appearing in the content of the individual interviews to derive fundamental meaning.

   Results Top

Perceptions and experiences associated with the North Korean refugee doctors' clinical and personal experiences of NCDs in North Korea were divided into six domains involving three categories. The six domains had a total of nine sub-themes [Table 3]. The North Korean refugee doctors participating in this study stated: that North Koreans did not have a high level of understanding and knowledge of NCDs, which NCDs are the highest priority diseases, that economic breakdown was the primary cause of the North Korean NCDs burden, and that a high priority should be assigned to targeting the NCDs of North Korea.
Table 3: Perception comparison by theme

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Perceptions and experiences of the NCDs burden in North Korea

As noted, NCDs were reported as being the highest priority diseases. The doctors all considered that emphasis on addressing disease burden in North Korea had previously been focused on communicable diseases (CDs) such as tuberculosis but, recently, the focus had changed to NCDs such as hypertension and stroke. However, they stated that while NCDs are considered to be underlying diseases of adults, tuberculosis is still widespread among children.

A-2. NCDs are underlying adult diseases

“When I think about the time of my escape from North Korea in 2007, I think there were differences between then and previously… I am a pediatrician… Children were malnourished in the late 1990s, and had tuberculosis in 2007. In adults, stroke and cardiac arrest were (more common)” (#F)

B-1. The extent of NCDs within North Korea's total disease burden

“(We) cannot diagnose chronic diseases. (If we do a test for a diagnosis,) there are many.” (#I)

“(North Korean government) emphasized chronic diseases a lot. (You) have to treat chronic diseases well this month. (North Korean government) emphasized every season.”(#D)

The North Korean refugee doctors considered that North Koreans did not have a high level of understanding and knowledge of NCDs. However, they confirmed that North Koreans routinely use folk remedies and treatments to treat and alleviate diseases. They pointed out that the North Korean government has made efforts to manage chronic diseases, but with limited effect. In particular, they noted that disease education is not effective in North Korea and, therefore, general lifestyle education and specific interventions such as smoking cessation are less likely to be effective.

C-3. Indifference to government health initiatives such as the anti-smoking campaign

“…I escaped in 2011. The North Korean government had instructed doctors to educate the North Koreans that if they stopped smoking, that would cure their illnesses. But there were no non-smoking zones.” (#B)

“… There is no need for diet control education in North Korea.” (#E)

“… (Drinking and smoking) education have no effect.”(#J)

Perceptions of the causes and background of the NCDs burden in North Korea

North Korean refugee doctors considered that the primary cause of the NCDs burden was economic breakdown, involving the collapse of the healthcare system, paralysis of the medical delivery system, and irregularities in medical resource allocation.

D-1. The main reason for NCDs burden economic breakdown

“… (North Koreans are) struggling to eat and live and cannot afford health care. The reality of North Korea is that my child is dying, but I must not get ill.” (#H)

“…After the Arduous March of the 1990s, the economy became more dysfunctional and the health system became a problem.” (#C)

Perceptions on addressing the NCDs burden in North Korea

The doctors considered that both addressing economic issues and improving the healthcare system were top priorities for resolving NCDs in North Korea.

A. Top priorities for improving the medical environment

“The health care system is the first.” (#E)

“…the health care system is the first and the remainder are the consequences of it.”(#D)

Education concerning NCDs for North Korean residents

The doctors indicated that a general lifestyle intervention was not likely to improve the populations' health status in North Korea. They considered that NCDs-related education would have no positive effect in North Korea.

C-1 Insufficient knowledge of all diseases including NCDs

“In North Korea, there is no need for food education.” (#F)

“In the case of exercise, walking is always necessary, so exercise is not necessary.” (#G)

“It is not harmful because residents do not know (health information). It is true that health care is difficult because of difficulty in eating and living. The reality of North Korea is that the children die (in hunger) and parents cannot afford to be cured of their illness.” (#H)

   Discussion Top

The main findings of this study were that the North Korean refugee doctors recognized NCDs in North Korea as a major problem, that they considered the North Korean healthcare system needed to be changed prior to addressing NCDs specifically, that as medical experts they confronted dilemmas in relation to their medical knowledge of diseases and the realities of economic hardship causing diseases in North Korean society and, finally, they considered that NCDs-related health education for North Koreans was of little value given the broader economic breakdown within North Korea.

The doctors considered that NCDs remained major health problems to be resolved despite long-term food shortages and economic difficulties in North Korea. This finding differs from previous media reports in South Korea and in studies on the health of North Korean refugees.[16],[21],[22],[23] The doctors made clear that NCDs were given a higher priority than CDs in their experience in North Korea. They also agreed that the North Korean disease pattern had shifted from CDs to NCDs, which differs from commonly held views that North Korea is suffering seriously from food shortages, leading to economic difficulties and, at the same time, is a backward country with diseases such as CDs.[4],[5],[6],[8],[24],[25],[26] North Korean defectors who have a formative influence on public opinion tend to agree with such commonly held views. This difference in perspective is fundamentally due to a gap in information acquisition and prejudice concerning North Korean healthcare, and needs to be overcome.

The doctors believed that changes in North Korean society should be prioritized in order to resolve North Korea's NCDs. In particular, they proposed reconstruction of failing North Korean social structures regardless of any specific targeting of health and health policy tools [2],[27],[28] as an appropriate response to the NCDs burden. The doctors' perceptions may be understood in terms of their individual experiences of extreme circumstances. This is because traumatic experiences that cannot be addressed by an individual or a group of people can be perceived as too overwhelming to be confronted at an individual or at a professional level.[29] For the doctors, a significant level of health indicators achieved by North Korea prior to the economic crisis seemed to have been a source of pride for medical personnel within North Korean society.[30] The doctors recognized that North Korean society requires a major transformation to recover to health levels that had been obtained previously.

The doctors perceived a conflict between their perceptions and experiences as medical professionals and their personal experiences as members of North Korean society involving economic hardship. The conflict meant that the doctors understood the social specificity of North Korea to be the cause of the increased NCDs burden. The doctors were medical professionals well aware of healthcare solutions, including medical interventions, as a solution to NCDs, but were also aware of the shocking factors that led to them. For the doctors, the period of extreme economic collapse, namely, the Arduous March of Hardship experienced in North Korea, was a traumatic factor and social experience.[31] Particularly, the doctors reaffirmed their traumatic experiences through dialogue among fellow participants. Health determinants include individual determinants and social determinants, and social determinants have played a significant role in the experience of these North Korean refugee doctors. The doctors claimed that even prevalent smoking and alcohol consumption habits in North Korea were due to the collapse of North Korean society and that the specificity of this society had led to the prevalence of stress, smoking, and alcohol consumption. However, North Korea had already had a high smoking rate before undergoing major social and economic breakdown, and the North Korean government continued to campaign for anti-smoking alongside the WHO.[32],[33] It was apparent that the North Korean refugee doctors did not perceive lifestyle factors such as smoking, alcohol consumption, lack of exercise, and nutritional excess as the main risk factors of NCDs. However, the burden of NCDs is highly influenced by aging and epidemiological transfer. North Korea is also a country where the elderly population is steadily increasing and the epidemiological transition had already progressed considerably prior to the period of the Arduous March.[16] Therefore, the perceptions of the doctors that the burden of NCDs is due to specific socioeconomic conditions is not consistent with expert opinion.

The doctors were convinced that education for North Koreans concerning NCDs was a pointless exercise. Medical staffs were advised on the education requirements of the North Korean government, but many issues remained unaddressed other than the NCDs, which seemed to render education a side issue. However, modern medicine and public health professionals generally do not hold this view.[34] Most deaths from NCDs are known to be preventable. For most NCDs, addressing lifestyle risk factors such as smoking, alcohol consumption, lack of exercise, and eating unhealthy food are critical for preventing these diseases.[35] The North Korean government also recognizes the importance of managing lifestyle factors according to the instructions of its leader, and carries out related education and campaigns for residents.[32],[33] The doctors' perception that NCDs-related education targeting the North Korean people is pointless does not mean that the North Korean government and medical personnel are not attempting to provide such education.

The doctors claimed that North Koreans generally have a certain level of self-care knowledge in areas such as folk remedies and palliation. However, the doctors also still claimed that North Koreans would be ignorant concerning NCDs. Although these doctors believed that NCDs education was pointless for improving the health status of North Koreans, it should not be concluded that the North Korean authorities do not need to consider NCDs-related education for North Korean people as additional preventative support. North Korea has not accurately publicized all national data and statistics, including health-related indicators. It is hard to find the North Korean government research or report that objectively evaluates the performance of health-related educations conducted for North Koreans. In this regard, more research is need.

This study has the following limitations. First, the number of participants in our study was small; therefore, our study findings do not have high explanatory power in interpreting and discussing research results. Second, the number of FGD was not large, and there was a lack of consensus within the various opinions expressed through active exchange among the participants. Third, the program designed for this study did not include sufficient questions and discussions to bring out diverse opinions and, thus, had limitations in deriving richer results. The lack of diverse questions and discussion served to limit the information available to the participants.

Financial support and sponsorship

This study was funded by Korea Foundation for International Healthcare, 2014. The authors of this paper are responsible for all contents.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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