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?"


Back at the Pyongyang Maternity Hospital, Mun, the facility's director of foreign affairs, steps off an elevator with flickering lights and begins spitting facts about the newly built Breast Cancer Research Center.

Here, it's like being transported to a heated exam room in the U.S. or Europe equipped with high-tech machines for mammograms, radiation and ultrasound. Mun refuses to say how much this new addition cost, adding only that one X-ray machine totaled 700,000 euros, or $910,630, and that the late leader Kim Jong Il and his successor son spared no expense. (Young Kim's mother is rumored to have died from breast cancer, but when asked, a hospital official declined to answer).

There was just one thing missing from the model health center: patients. A waiting room with rows of shiny chrome benches is deserted, while a lone nurse sits almost hidden behind a towering work station. Mun says 80 of the hospital's 100 beds are full, but only one room shared by three women is shown.

"This morning there were many patients," says Pak Hyang Sim, director of the hospital's diagnostic imaging. "They were all diagnosed. That's why it's so empty now."

Defectors and aid workers say hospitals everywhere are often eerily vacant. Bad roads, a lack of transportation and no money make it impossible for many to access health centers. Medicine and care are supposed to be free. But in reality, everything has a price.

"There's a saying in North Korea: If your relative has cancer then your entire family is ruined because everything will go to getting that medicine," says Jeon, a 24-year-old defector in Seoul who fled North Korea five years ago and asked that only one name be used to safeguard her father still living across the border. "Some families who can't afford the medicine have no choice but to watch their loved ones die."

Despite the new center, breast cancer is far from the top of the list of health problems gripping the country, revealing a disconnect between where the government spends and what the people really need.

Hunger remains perhaps the biggest health concern, with 16 million North Koreans — two-thirds of the population — not getting enough to eat. The resulting malnutrition exacerbates a range of health issues, from hijacking child brain development to maternal death.

In the famine of the 1990s, hundreds of thousands of North Koreans are believed to have died. The government launched a "let's eat two meals a day" campaign, and people foraged for bark, roots and grasses, according to the Amnesty International report.

The period, known inside the country as the "arduous march," left a devastating mark on its overall health despite food aid from the international community that continues today.

Child stunting rates remain high, at 28 percent nationally and 40 percent in the worst-hit isolated province of Ryanggang. North Korean men are up to 3 inches shorter than their South Korean counterparts, according to findings published two years ago by Daniel Schwekendiek, an economist at Sungkyunkwan University in South Korea. North Koreans also can expect to die around 12 years earlier than their southern neighbors.

However, some say the outside world's perceived picture of health may also be skewed. North Korea, for instance, has lower stunting rates than Cambodia, Indonesia, Laos, Myanmar and Nepal.

"We think it's a constant situation where you find malnutrition or you find undernutrition or you find people not well fed," says Gerhard Uhrmacher, program manager for the German humanitarian aid organization Welthungerhilfe, who has traveled extensively in North Korea over the past decade. "This is generally almost all over the country, but it's not to the extent where hundreds of thousands of people are dying. We don't believe that."

He says the government's propaganda machine also twists reality to fit its needs. He recalls foreign journalists a year and a half ago being shown a hospital "where they took children who were in very, very bad shape to reinforce their request for food aid."


At the Kyongsang Clinic in Pyongyang, the impact of donor money is on display, along with pageantry and a heavy dose of propaganda. Plump children in pouffy bright traditional dresses and military uniforms howl in their mothers' arms, as nurses force crushed Vitamin A tablets and chalky deworming pills into their mouths. In a nearby nursery, children take the medicine and then go onstage to sing traditional songs praising the leaders.

The campaign, supported by UNICEF, reaches 1.7 million children twice a year. Eliminating parasites helps combat malnutrition, but it's clear none of these kids are going to bed with empty bellies.

The clinic does, however, showcase one of the bright spots in a generally bleak scene: A focus on prevention, which is central to the overall health system.

In the early years, North Korea set up an army of household doctors, each responsible for overseeing basic health within their communities. Tens of thousands of these physicians still exist today, with one doctor responsible for about 130 households.

North Korea has been applauded by the WHO and others for its mass mobilization, successful child immunization programs and health promotion — systematic approaches commonly deployed in top-down socialist countries. These programs are among the few reminders left of a free universal health system that in the 1960s boasted more hospital beds and a lower infant death rate than the South.

Now, it's mostly Pyongyang that benefits.

At the new breast cancer center, guide Mun stops on the stairs to show off a wide strip of jade-colored marble that "looks like a waterfall flowing down." He explains that the wooden railing was replaced with stone because Kim Jong Un thought anything less would cheapen the facility.

A female doctor later stops to point out shimmering prisms dangling from a golden chandelier before leaning in to whisper: "Look closely, doesn't it look like a breast?"

At the end of the tour, in a room with photos of founding leader Kim Il Sung and son Kim Jong Il looming overhead, Mun hands visitors a large guest book filled with pages of messages scrawled in many languages.

Please write your impression of the hospital, he says smiling, handing over a pen.


Associated Press writer Elizabeth Shim contributed to this report from Seoul, South Korea.


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