PYONGYANG, North Korea — In the lobby of Pyongyang's maternity hospital, a government guide pauses during a tour, pointing down to an elaborate flower pattern glowing in buffed red and green marble.
"One hundred and sixty-five tons of rare stones were used on the floor," Mun Chang Un proudly tells the foreign visitors being offered an unusual glimpse inside.
He walks toward a row of tiny booths with mounted TVs, video cameras and '70s-style phones, explaining that the "high-tech" conferencing stations are used to protect mothers and newborns from visitors' germs. Just a few floors upstairs, he says, a well-equipped breast cancer center was recently opened under new North Korean leader Kim Jong Un.
It's a rehearsed picture of health the reclusive government wants the outside world to see, complete with spotless granite corridors. But the reality of that image is clouded every time Mun takes a breath that explodes into icy wisps.
The hospital is so cold during this February visit, patients remain bundled in thick coats, gloves and scarves during exams, while nurses swish with every step as they hustle through the halls in white snow pants and matching puffer jackets. Mun himself wears big, furry teddy bear slippers.
The contrast raises one fundamental question: If there's no heat in many parts of one of the country's best showcase hospitals in Pyongyang — where temperatures can plummet well below zero — what type of health care exists at small clinics in the rugged mountainous countryside where even government officials say electricity and running water are sometimes hard to find?
As with so much in North Korea, it's difficult to know what the true overall picture of health really looks like beyond the face presented. Only a handful of foreign aid groups and U.N. agencies operate in the country, and none of them can move around freely. Some areas remain totally off limits.
Even in the gleaming capital, some health facilities appear to be a throwback to another time. Hulking machines and antiquated equipment in exam rooms could have arrived decades ago, when there was still a steady flow of medical supplies from the former Soviet Union.
The government also typically collects and analyzes health data, raising questions about accuracy and sampling methods. Some prominent foreign aid workers in Pyongyang say they were initially skeptical, but now trust the numbers after independent attempts to check their accuracy revealed similar results.
Yet even the Ministry of Public Health's own recent reports reveal glimpses into a system where all is not well. More than one in four children under 5 years old suffer from stunted growth due to a chronic lack of food; tuberculosis is raging within the country; infant death rates have jumped to levels higher than in the 1990s.
Foreign doctors, aid workers, North Korean defectors and various reports, such as a scathing 2010 assessment by Amnesty International, paint an even darker picture.
They describe beer bottles used as IV drips and broken legs splinted with sticks instead of plaster. Amputations performed without anesthesia. Dirty needles reused. A husband holding up a candle while a doctor removes a fetus from his hemorrhaging wife. Surgeons operating with Soviet-era instruments with no heat or running water.
The health system has crumbled and languished over the past few decades amid deepening poverty and desolation. Government health spending ranks among the world's lowest, with one World Health Organization estimate putting it at less than $1 per person in 2006.
Pyongyang's nuclear ambitions have resulted in further isolation and years of crushing international sanctions, with the toughest-ever restrictions coming after the country's third nuclear test in February. Humanitarian aid is not supposed to be affected, but health officials say the sanctions have made it difficult to import medicine and supplies.
Donors have also been reluctant to offer support amid rising tensions. The United Nations recently reported a desperate shortage of funds for its North Korea operation, resulting in a scarcity of drugs and vaccines for children and pregnant women. The country also lacks the basic health infrastructure and hygiene to reduce diarrhea and pneumonia, the two biggest child killers worldwide.
"Overall, it's a stark contrast between Pyongyang — which is the window to the world for North Korea — and the rest of the country," says Katharina Zellweger, who has traveled to every province during nearly two decades of humanitarian work. She routinely found clean facilities with old equipment, limited drugs and intermittent supplies of water and electricity. "There is an extended health infrastructure across the whole country. The question is really how well does it function?"