Notable features of COVID-19 programmes in KCNA

Programmes concerning COVID-19 broadcast from January 2020 to May 2022, from the beginning of the pandemic era to the first time period of official cases, were analysed in this paper. Latest figures on COVID-19 worldwide and propaganda materials accounted for a large proportion of programmes throughout the entire period, while educational programmes that offered preventive measures were intermittently included from the beginning of the outbreak. An upsurge in the number of programmes was observed in May 2022, with a relative focus on the clinical aspects compared with the period before the first official acknowledgement of cases. An increase in the frequency of programmes in each subgroup (ie, home-care management, instruction for medication usage and post-COVID-19 conditions), one after another, was observed during the recent period.

Detailed instructions for usage of medication were impressive feature of the programmes in KCNA, the state-run news agency that broadcast programmes to laypeople without medical expertise. The usage of medications with specific dosage guidelines (eg, oral administration, intramuscular or intravenous injection) was explained by some of the medical professionals who appeared in the television programme, mentioning both the generic and trade name. Additional evidence will be required in order to determine whether the instruction provided in the broadcast programme plays only an auxiliary role to the formal prescription from their doctors or the essential explanation to understand the exact usage of self-prescribed medications, however, considering the damaged healthcare system and expanding informal market for medication in North Korea, both interpretations are plausible.7 20 It is assumed that authorities are aware that drugs not fully provided under the current healthcare system are being purchased unofficially in the marketplace; elaboration on the usage of medications in television programmes can be regarded as an endeavour by authorities to supplement the systematic limitations in healthcare sectors that are aggravated during the pandemic era. Expecting precise discrimination of the generic names or understanding of the detailed adverse drug reactions from the laypeople watching the television programmes may be laborious, however, people may recognise and learn basic instructions for usage of medication from the educational programmes.

Drug overuse, misuse and adverse drug reactions were part of the critical points from the education programme instructing medication usages; medical professionals repeatedly issued warnings to avoid abuse of antibiotics, antipyretics or painkillers. It was suggested that almost half of the cumulative deaths were the result of adverse drug reactions in May 2022 (32 out of 68 deaths), and the recent figures would not be significantly different as only 74 cumulative deaths were reported by authorities at the point of the declaration of victory in August 2022. Despite the extremely low reliability of the statistics with a double-digit death toll, the concern regarding drug abuse and adverse drug reactions in North Korea appears to be significant.

Many North Korean refugees are known to expect the immediate effect of medication, which eventually leads to drug abuse21; the medication might likewise be overused by North Korean people, formally prescribed by doctors or self-prescribed, in order to immediately manage the symptoms of COVID-19. One possible scenario of deaths from adverse drug reactions is paracetamol; reports on the patient population in Pyongyang suggested that more than one-third of the patients had fever higher than 39.0°C.2 The absence of vaccination campaigns may have exacerbated the degree of symptoms after COVID-19 infection and led to overuse of antipyretics including paracetamol without professional guidance. Paracetamol-induced acute liver failure in some unfortunate population may account for some portion of the deaths resulting from adverse drug reaction.22 23 Antibiotic resistance resulting from overuse of self-prescribed antibiotics can also pose a secondary threat in North Korea, where the burden of infectious diseases remains high.24

Therefore, the concern for appropriate usage of medication might accompany humanitarian assistance including medication support. Proper monitoring of drug distribution and patient education should be required after administration of support, however, because the monitoring is regarded as outside interference, the health authorities would refuse the evaluation process. Door-to-door delivery of medication or community doctor visits for the self-quarantined in North Korea have been suggested as an appropriate healthcare project to help people overcome the COVID-19 pandemic, however, there are questions regarding the coverage and sustainability of the services. Conduct of further studies on public healthcare services in North Korea will be required in order to verify the integrity of the system.

Understanding the aims and priorities during the pandemic

The variables exploited in the paper to briefly figure out the aims and priorities of the authorities (ie, the results of quantitative analyses on KCNA and the trade volume between two adjacent countries) mirror the ‘educational endeavours for disease control’ and ‘balancing efforts between epidemiological and economic survival’, respectively. The intentions of the authorities are presumed to be rapidly reflected in their educational endeavours, considering the characteristics of state-run media, compared with the reflection in trade sectors that require complicated collateral administrative procedures. The analysis in the paper revealed that the frequency of the KCNA programmes broadcast concerning COVID-19 was numerically in the opposite direction to the fluctuation of the trade figures between North Korea and China during the early and mid-term of the pandemic. The results indicate the matching aims of disease control by the means of public education and border closures under the hypothesis that the shrinkage of trade volume may have originated from stricter border closures influenced by the fear of COVID-19, in addition to the effects of long-standing economic sanctions.4 North Korean exports in the early periods (ie, January 2020 to December 2020) were negatively correlated with the media coverage, while overall trade volume and North Korean imports showed a negative correlation with the broadcast during the early and mid-terms (ie, January 2020 to December 2021).

The difference in the proportions of North Korean exports (11.8%) and imports (88.2%) among overall trade volume (approximately $1.2 billion) during the included periods (ie, January 2020 to May 2022) may provide possible explanations for the time gap in correlations.19 The intention of the authorities to strengthen the border closures, originated from the concern regarding COVID-19, is estimated to be first reflected in the exports that account for less proportion of the total trade volume. The North Korean imports that account for most of the trade volume are estimated to be affected in relatively long-term periods as the imports (eg, industrial and consumer goods) were directly connected to the livelihood of North Korean people due to the unbalanced industrial structure and struggling economy.19 25 The figures of both exports and imports as shown in online supplemental figure 2 may provide insights into monthly trends, aside from the significance of correlation.

The unanimous direction of the figures found in the early and mid-term of the pandemic may also substantiate the utility of media analysis to grasp the situation while providing hints to the over-riding concern on disease control. Significant correlations shown in the preliminary analysis provide further possibility of KCNA programmes to be used as meaningful indicators in North Korean studies, while the methodology also demonstrates its strength that the data needed for quantitative analysis of public media can be promptly acquired compared with the figures released from the governmental offices.

However, the correlation between the trade figures and media coverage disappeared with inclusion of recent figures (ie, January 2020 to May 2022). The gradual resumption of trade between the adjacent countries, except for the last month with the official acknowledgement of COVID-19, is estimated to be influenced by viability issues from the economic crisis induced by long-standing border closures and sanctions; the immediate question of life or death appears to have overwhelmed concerns on the virus in recent days. Analysing the emerging disjunction between two sections: (1) educational endeavours for disease control and (2) balancing efforts between epidemiological and economic survival, may be helpful in understanding the ulterior motives of the authorities to survive under multiple threats. Trade figures fluctuated after the first acknowledgement of COVID-19 in May 2022, thus there is a demand for conduct of further studies on the association between two indicators. The consideration of additional variables including pre-existing sanctions or climate problems unfavourable to agricultural outputs in the analysis would provide further insights to understand the relationship.

The trade volume between the two adjacent countries was introduced in the study to peep through the intention and priorities of the health authorities. The index as a secondary indicator of border closures and degree of concern on COVID-19 may provide hints and implications to understand the North Korean policies, but still needs to be interpreted with caution. More evidences and variables, including the specific sectors of trade or contemporary COVID-19 statistics of adjacent countries, are required for an in-depth analysis of COVID-19 managements.

The appearance of COVID-19 variants, for instance, is suggested to have influenced the border closures between North Korea and China.19 The number of the confirmed cases of Omicron variant in China during the included periods, or the proportion of variant among all confirmed cases, may therefore become one of the key factors to understand the direction of border closures. The data acquisition for variants in China is, however, extremely difficult as reliable information is not provided in public; only partial set of data, including the vaccination statistics or counts of confirmed cases and deaths, can be acquired from the database.26 The health authorities of South Korea, another country adjacent to North Korea, are meanwhile regularly releasing the official figures on the COVID-19 variants, but the analysis of South Korean figures would be irrelevant in North Korean studies as their border does not ordinarily allow the exchange of human and material resources, ultimately preventing the inter-country spread of the virus.27 Further information is needed to explain the significance of the variant, or other significant factors, on the North Korean policies and the association between the trade volume and media coverage.

Reliability of COVID-19 statistics in KCNA

The daily number of cases with fever in North Korea was reported in KCNA as a proxy of confirmed cases, although the term ‘people with fever’ is not equivalent to ‘COVID-19 confirmed cases’.2 5 Clinical guideline from WHO recommends the healthcare providers to collect respiratory specimens for suspect cases, but the limited capacity in North Korea to carry out the procedures in a large scale pressured the health authorities to choose the alternative.5 28 Screening the fever cases under these limited conditions can still be one of the best options as it fulfils the primary objective from the guideline to find and isolate every suspect COVID-19 case to stop transmission.

Despite the utility in establishing general disease control policies, the application of the proxy and simplification of diagnosing procedures may inevitably lead to statistical and clinical errors owing to shortage of detailed information. Asymptomatic patients with COVID-19 are completely disregarded from the statistics, while the populations suffering from fever due to other infection sources are not provided with proper management. The deaths of COVID-19-infected people, especially the elderly with underlying disease, can meanwhile be included in the death toll irrelevant to COVID-19 mistakenly or intentionally. The misclassification of the deaths of patients with underlying disease might cause underestimation of the COVID-19-related mortality in the elderly while relatively overestimating the mortality in child population; children under 10 years old were reported to account for 16% of the COVID-19-related deaths in North Korea (interim figures in May 2022).2 The number and demographics related to COVID-19 cases are therefore debatable; more detailed information needs to be unveiled.

The absence of new confirmed cases in North Korea after the ‘declaration of victory against COVID-19’ is also questionable; it is rather reasonable to expect sporadic outbreak in a small scale. KCNA as state-run news agency might be using the modified statistics for political purposes, while local healthcare workers and patients with COVID-19 may both conceal the cases to evade the responsibility and penalty. The authorities are currently reported to be encouraging their people to voluntarily participate in preventive healthcare services under the concern of possible COVID-19 resurgence.29 Further studies on the broadcast direction whether to acknowledge new COVID-19 cases are needed during the possible resurgence periods.

Limitations and implications

The analyses included in the paper are based on the list of the broadcast programmes obtained from the database, however, the actual programme broadcast in KCNA differed intermittently on a small scale from the established television schedules (eg, omitting prearranged programme, rescheduling the broadcast timetable). Monitoring thousands of hours by limited number of researchers in order to confirm the differences in entire 24 448 programmes broadcast from January 2020 to May 2022, including those not related to COVID-19, was physically impossible. It is therefore possible that the frequency of subgroups of each programme classified and reported in the study may show unavoidable differences from the actual programme broadcast, however, the degree of discrepancy was not significant to damage the entire results and influence the trend of the programmes.

The design and data access of the study were conducted from April to June 2022, therefore, data from June to August 2022, the period after the sharp increase in cases of COVID-19 in May to the asserted end of the crisis in August, were not included. Extra analysis of the broadcast programmes allocated to COVID-19-related issues will be required in further studies.

However, findings from the study provide meaningful insight into how the public media was used by North Korean authorities to educate their people in the situation of the COVID-19 pandemic. To the best of our knowledge, it is the first paper to provide a quantitative analysis of the long-term media programmes in order to understand clinical guidelines for COVID-19 in North Korea. Instructions for patients with COVID-19 and their symptoms were elaborated, while the trends of programmes on COVID-19 were also illustrated. A peculiar feature of North Korea is that the intentions of the authorities are fully, rapidly reflected in the public media, emphasises the importance of the study in evaluation of healthcare policies.

The results of the study provide clues that can be used for indirect interpretation of the currently damaged healthcare system and widespread drug abuse behaviours in North Korea, consequently underscoring the necessity of proper monitoring of medication distribution and patient education. The preliminary comparison of the media coverage and trade area helped highlight the priorities and aims of the authorities; the over-riding concern on disease control was observed in the early and mid-term of the pandemic, while the viability issues were estimated to have recently influenced the direction of policies. More evidences are still needed to conduct an in-depth analysis; essential factors such as economic sanctions need to be considered for a detailed approach.