When free medical treatment is not free

Credit: istock.com/Golden Brown

“Oh, are you a North Korean defector?” the South Korean man at the book club asked me politely. “If it’s not too intrusive, may I ask you something?” 

He went on to ask me a question related to healthcare and medicine, which was his field of study.

This man seemed to have read a lot about how healthcare works in North Korea. It was odd for me to listen to him talk about it because I’d never had any hospital treatment when I lived there. I felt I should have known more, but frankly it was all quite unfamiliar to me. 

Healthcare in North Korea, he explained passionately, was based on socialist principles and established there in a unique way. He emphasized, for example, one key characteristic which was that all treatment was free. 

“Do you remember going to hospital and being prescribed medicine?” he asked.

 “I never received medicine,” I said. I really had no such recollection. But this did not seem satisfactory to him.

“I know defectors often speak negatively about North Korea,” he ventured. “But still, as a nation, North Korea does operate hospitals. It’s hard to believe you weren’t given any medicine.”

I must say I found this response truly intriguing. I’ve often found myself disputed in this way.

When it first happened, I really tried to understand why. That was when I came across the concept of confirmation bias. Coined by British psychologist Peter Watson, this idea explains how we tend to seek information that supports our existing beliefs and ignore or downplay information that contradicts them.

I think that’s what my book club friend was doing. I was telling him my experience but it didn’t fit what he felt he knew to be true. What he couldn’t see was how we were both right.

He was correct in that the healthcare system does provide free treatment. However, the contradiction lay in the fact that, if hospitals are not functioning properly, there is no point to go to them and thus no experience of free treatment.

North Korea’s healthcare system has three main features: besides free treatment, it has a system of preventive medicine and a household doctor system. The state owns all healthcare-related facilities and equipment. Medical personnel are also all directly employed by the state. 

Comprehensive free treatment has been in place in theory since 1960, following the enactment of the 1947 Social Security Act. But without any formal legal changes, the practice ended in the 1990s.

It is true that surgery remains free. But patients have to pay the hospitals for the necessary medication and so the doctors can get their salaries. If a person can’t pay, they don’t get the surgery.

During the pandemic the central government said local party committees had to tailor production of vaccines to local needs and take responsibility for all research, production, and technical and personnel issues. In North Hamgyong Province, for example, the provincial party committee convened a meeting of over 100 department-level leaders and technicians to figure out how to comply. The result gives a sense of the status of the healthcare system.

“Party workers distributed basic medication, food supplies, and firewood from their own homes as part of the infectious disease control measures,” said Han, who ran a business in Cheongjin, the provincial capital. “Basically, they provided a few pills and some unpalatable food items. Seeing this, people got angry, saying, ‘Are you mocking the poor?’ Even food given to comfort babies shouldn’t be this pathetic.'”

Kim, a hospital assistant in Kyonghung County in the northeast of the country, said her facility had ambulances, but that patients had to pay for the gasoline. 

“When lives are at stake, people will pay if they can. But most either walk or are brought in on carts or makeshift stretchers. In rural areas, even the stretchers have to be paid for,” she said.

“Free healthcare is a facade,” she added. “When you see people dying and others trying to escape, you can’t help wishing North Korea would just open up and allow people to earn money. That way they could afford medicine and live. It’s a thought that crossed my mind countless times.”

A defector from Hoeryong said that the United Nations gets tricked into sending supplies. “I don’t see why they send medical supplies,” she said. “The Hoeryong People’s Hospital is designated for UN inspection visits. When that happens, nurses put on gowns and lie down as if they are patients.”

Lee Myeong-hee, 50, from the Chongam district of Cheongjin, confirmed that supplies labeled as UN aid often arrived at the city’s hospitals. 

“However, they are not provided to patients. Doctors usually take them for their own use or for high-ranking officials,” she said. She added that she occasionally received such supplies because she had relatives who work in the hospital.

Some doctors are known to openly charge for medical treatment. 

“My brother called from North Korea to ask if I could buy MRI equipment,” said Choi, 38, a defector now in the South. “He’s completed his medical training and been assigned to a hospital.” 

Doctors who bring equipment to their hospital can earn money, Choi explained. 

“For example, if they charge 100,000 won per examination, 20% goes to the hospital and they get to keep the rest,” he said. “If I can collect a little more to buy that equipment, my brother will be able to support our family on his own.”

Citizens also rely on folk remedies and opium for relatively simple illnesses. 

“For inflammation or headaches, there’s no need to go to the hospital,” said Choi, who escaped from the North with her grandmother. “Even if you do go, there’s hardly any medicine. My grandmother suggested mulberry root to me for inflammation. When my headache was unbearable, like my head was splitting and I was cold and sweating, she dissolved half a grain of opium in water and gave it to me.”

Lee Jia

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