Senior aid worker Kathi Zellweger first visited North Korea in spring 1995 when the country experienced devastating floods and famine. She witnessed a healthcare system on the verge of total collapse.

"I would see children on a drip, and the drip was an old beer bottle," Zellweger recalls. "Hardly any medicine around. Medical staff sent to the woods to find edible food. Hospitals were often empty, because if electricity doesn't work, water supply is questionable, and family members have to bring in food, so you might as well stay at home."

Over the next three decades, Zellweger made 75 trips to the Democratic People's Republic of Korea (DPRK), lived in Pyongyang for five years (2006-2011) while serving as country director for the Swiss Agency for Development and Cooperation, and founded KorAid Limited, a nonprofit focused on serving North Korean children in institutions and people with disabilities – the subject of a working paper she published while in residence at APARC as a 2011-13 Pantech Fellow with the center’s Korea Program.  

In a recent interview hosted by Karen Eggleston, director of APARC’s Asia Health Policy Program, Zellweger reflects on her life’s journey of engagement with the DPRK and discusses her recently published memoir, Miss Kathi: Saving Lives in North Korea (Spring Hill Press, co-authored with Mike Chinoy). In this conversation, Zellweger also assesses North Korea’s changing healthcare system, the unintended consequences of global sanctions, and the urgent need for renewed humanitarian engagement with the country.

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A Health System in a Shortage-Based, Centrally-Planned Economy

North Korea officially maintains a state-run healthcare model inherited from the Soviet era, but in reality, that guarantee has eroded.

"There is no longer universal free healthcare," Zellweger explains. “The infrastructure is there, but is not being fed properly.”

The North Korean health system spans central hospitals in Pyongyang, provincial and county facilities, and village-level clinics. Yet outside the capital’s showcase institutions, facilities remain hollowed out, with severe shortages of equipment, medical supplies, and staff training.

"You can have very updated, modern facilities, but you need to know how to use them," Zellweger says. “There have been some improvements, but there is still a long way to go.”

She noted that “even Kim Jong Un described countryside living as century-old backwardness.” In 2024, Kim launched the Regional Development 20×10 Policy, which aims to modernize infrastructure across 20 counties each year over the next 10 years. Yet, with the country's borders sealed since late 2019, independent observers must rely on satellite imagery and state broadcasts to gauge progress.

A Chokehold on Humanitarian Aid and a Call for Reengagement

North Korea is subject to strict international sanctions, which, although designed to deter the DPRK’s nuclear and ballistic missile programs, have paralyzed humanitarian delivery mechanisms.

"Sanctions of course hinder aid going in," Zellweger points out. "For example, everything containing metal needs approval from the UN. That’s a huge bureaucratic process which a small NGO simply cannot afford – you need a lawyer for that."

The result has been a chilling effect on standard medical shipments, from basic diagnostic devices to surgical instruments and water sanitation hardware. Meanwhile, the population’s nutritional baseline remains precarious. More than 40 percent of the DPRK’s population – almost 11 million people – remains undernourished, subsisting on carbohydrate-heavy diets devoid of vital proteins, fats, and micronutrients, according to UN data.

“I do wish the UN agencies would be back to help, especially the WHO and UNICEF in the health care sector and also NGOs who worked in the medical field or with people with disabilities,” says Zellweger.

With North Korean troops deployed alongside Russian forces in Ukraine and Pyongyang leaning into tighter alliances with Moscow and Beijing, Western political appetite for North Korean engagement has plummeted. Yet Zellweger argues that turning away from the civilian population is both a humanitarian tragedy and a strategic mistake.

"For me, engage, engage, engage is what is important, especially at this time when North Korea is focusing on Russia and China," Zellweger emphasizes. "We should never forget the people in the countryside who still need our support."