The Korean War Against Malaria

Posted June 9, 2008

In the years following the Korean War (1950-53), malaria-eradication campaigns successfully reduced the number of new cases of the disease on the Korean peninsula. In 1979, the World Health Organization (WHO) declared North and South Korea malaria-free. However, the disease unexpectedly re-emerged in the late 1990s and still persists today. The story of malaria in Korea is complex and has many facets, not only biological and environmental but also political. Could the disease bring the two Koreas closer together?

The Korean War worsened the malaria situation on the peninsula. To tackle the situation, the South Korean government established the National Malaria Eradication Program (NMEP) in 1959. This program, with technical assistance from the WHO, discovered that most malaria cases were in the Gyeonggi and Gyeongsangbuk provinces in the northern and eastern parts of South Korea, respectively. Gyeonggi province, the most populous in South Korea, is located along the border with North Korea.

The NMEP’s comprehensive eradication efforts resulted in a decline of cases in the 1960s. The improving socioeconomic status of South Korea and the modernization of farming practices, such as the increased use of pesticides, further decreased the number of cases in the 1970s. In its Weekly Epidemiological Record, the WHO declared South Korea malaria-free in 1979. No new cases were identified for several years thereafter, until in 1993, when a South Korean soldier was diagnosed with malaria. Over the following years, the number of cases increased rapidly, reaching a peak of 4,142 cases in 2000. This number has dropped to 2,021 cases in 2006. Considering that most cases are identified in the northern part of South Korea, this puts the general population there as well as military personnel along the DMZ at increased risk for malaria.

Less is known about the North’s fight against malaria but it seems to have experienced a similar trend as in the South, namely, it too was declared malaria-free in 1979 by the WHO, followed by a re-emergence of the disease in the late 1990s. Malaria was detected in the Kangwon and South Hwanghae provinces and the city of Kaesong in the south of North Korea. Just as for the South, most cases are identified along the DMZ but the total number in the North is strikingly higher with a peak of around 300,000 cases in 2001. This has dropped to 7,436 cases last year.

The type of malaria in Korea, vivax malaria, is the predominant human malaria species world-wide with most cases occurring in Southeast Asia and the Western Pacific, primarily among young children and infants. The disease rarely causes death but its symptoms, including fever, chills and vomiting, are very debilitating. More severe manifestations, such as rupture of the spleen, have also been reported. Vivax malaria can be treated with drugs, such as chloroquine, but resistance is increasing. Health-care costs rise as a result of expenses for anti-malaria drugs and doctors visits. Also, patients are unable to go to school or work for at least three days. To make things worse, vivax malaria is able to relapse after the cure of the original infection. This further increases the socioeconomic impact of the disease and complicates its eradication. As such it is not a disease that can be neglected and represents a very real public health threat.

The re-emergence of malaria in Korea may be due to the fact that it was never truly eradicated. Despite the WHO’s declaration in 1979, it is plausible that the disease persisted in low numbers, which remained undetected and unreported. Reduced emphasis on malaria control by both Korean governments after 1979 may have supported its survival. Increased rainfall and floods in North Korea in the early 1990s created more mosquito breeding places and drowned cattle, the preferred source of blood for mosquitoes, which were now forced to feed on humans. This, together with the rise of anti-malaria drug resistance, may have resulted in an expansion of the disease. Another factor that may have contributed, which has received more attention in recent years, is global climate change. In its publication “Protecting health from climate change”, the WHO warns that “many of the major killers are highly climate sensitive” and that warmer temperatures can favor their transmission.

Now that malaria is back in Korea, the North and South Korean governments have no other choice than to continue their malaria control programs. Their control strategies should be comprehensive and include the distribution of anti-malaria drugs, mosquito control and the implementation of public education programs. Both countries should focus their eradication efforts on the high-risk area along the DMZ where most cases of malaria have been identified. As in the past, the WHO should continue to assist both Koreas with technical support. Also, food aid to the North is needed during times of famine because malnutrition increases susceptibility to diseases, including malaria. Collaboration between the two countries in the fight against malaria should be encouraged because it is highly unlikely that either country will become malaria free when the other one is not.

Both Koreas have stepped up their efforts against the disease after the reoccurrence of malaria on the peninsula. The South Korean government started a 10-year program to re-eradicate malaria by 2010. The program encompasses enhanced detection and treatment of malaria cases, mosquito control and improved collaboration between civilian and military sectors. The North Korean government started a national malaria-control project in 1999. However, the main constraint the North is facing is a chronic shortage of resources to effectively fight malaria. Kim Moon-soo, governor of Gyeonggi province, visited North Korea in May this year to discuss food aid and malaria, Reuters reports. He is worried that infected mosquitoes from the North cross the Demilitarized Zone and infect people in his province. Mr. Kim wants the two Koreas to catch mosquitoes together but “the North has replied that it has no problem with malaria,” he said. “They are reluctant to have the issue publicized.”

South Korea’s Unification Ministry has financially supported North Korea’s anti-malaria campaigns for seven years, with annual aid rising from $530,000 in 2001 to $1.41 million in 2007. However, the approach of South Korea’s new president, Lee Myung-bak, toward aid to the North is different than the “Sunshine Policy” of his predecessors. Under Mr. Lee’s rule, the North would have to make serious concessions in order to receive aid, including the complete surrender of its nuclear program. Only then, will the South start its “Vision 3000” plan to help increase the North’s average per capita annual income to $3,000 within a decade. It remains to be seen whether South Korea will increase inter-Korean public-health efforts until Pyongyang complies with the “Vision 3000” terms—it is also questionable whether the North will accept the plan in the first place. At least for this year, South Korea provided the North with $1.18 million worth of supplies to help prevent malaria. On May 15, South Korean officials, including Governor Kim Moon-soo, personally saw the vehicles carrying malaria-prevention supplies off to North Korea.

Malaria is not a top priority for the Korean governments at the moment. Other pressing issues, such as nuclear disarmament of the North, are clearly higher on the political agenda. Also, the Koreas each have their own internal problems to worry about. The South faces a political crisis by fears that imports of American beef could expose the public to mad cow disease whereas, on the contrary, the North is confronted with extreme food shortages.

The WHO has been playing a crucial role in helping the Koreas eradicate malaria. It provides essential technical expertise and shares its lessons learned from successful malaria eradication campaigns elsewhere. The WHO is familiar with past and current malaria campaigns of North and South Korea and it has a good understanding of the healthcare infrastructure of each country. Furthermore, the WHO may even bring more interaction and a better understanding between the two Koreas by means of public health. Its Health as a Bridge for Peace (HBP) concept, which was established by the World Health Assembly in 1998, focuses exactly on this kind of “health diplomacy.” HBP provides training for health personnel in conflict prone or affected countries to gain the necessary knowledge and skills to identify opportunities for peace building. Needless to say, the medical teams dispatched to North Korea should receive this training. The influence of this subtle diplomacy may be hard to measure but it will certainly contribute to improving inter-Korean relations when political strategies seem to be making little progress.

Besides the WHO, several nongovernmental organizations provide medical aid to North Korea. The power of these organizations should not be underestimated at a time when political barriers between North and South remain. For example, the South Korean government recently asked the Korea Red Cross to act as an intermediary to offer food aid to the North. Other health-care-oriented NGOs with a long working experience in North Korea include the Eugene Bell Foundation and Mercy Corps International. Yet malaria is not their direct concern. These organizations are confronted with more urgent medical issues, such as the distribution of essential medicines and medical supplies, and other diseases like tuberculosis.

Does this mean that all South Koreans need to sleep under a bed net, take antimalaria medication, and walk around shielded by a thick layer of mosquito repellent? This used to be the case only for military personnel near the border. But times have changed. According to Dr. Chae Jong-Il, a parasitology professor at Seoul National University, today an equal number of diagnoses are being made within the general population in South Korea, Yonhap news agency reports. “Given that most of the infected civilians reside in villages some 10 kilometers or more away from the border, the re-emerging malaria is beginning to be indigenous in South Korea,” he said.

Malaria offers the two Koreas a unique opportunity to work together on an important, yet low-profile, problem that affects both countries. With the right amount of attention, drastic improvements can be made and this would represent a positive step forward in inter-Korean relations. In order for this to succeed, the South Korean Unification Ministry needs to continue to support the North with anti-malaria materials, no matter whether Vision 3000 is accepted or not, because North Korea clearly does not have the resources. The establishment of an inter-Korean malaria taskforce comprised of representatives of the North and South Korean ministries of health, local government officials and health departments of the provinces on both sides of the DMZ as well as the WHO and NGOs is needed in order to attack the disease on all fronts and reach the ultimate goal of re-eradication of malaria on the Korean peninsula. It is of uttermost importance that all parties are actively involved as they have nothing to loose and much to gain from this cooperation.

Dr. Frank Konings holds a doctorate in microbiology from New York University. He studied malaria in Africa and worked as an epidemiologist at the New York State Department of Health. He currently resides in Seoul.