Health and disaster diplomacy in North Korea: ensuring access and accountability in complex political environment.

and Zimbabwe have disproportionately affected vulnerable civilian populations and have been complicated by political restrictions on humanitarian access. 1 In areas frequently embroiled in war and political instability, aid agencies often face the challenge of negotiating with militant authorities in order to secure access. This is not a new problem. The challenge of negotiating access with militant authorities has been discussed and has led to philosophical disagreements between leading humanitarian organizations such as Médecins sans Frontières and the International Committee of the Red Cross/Red Crescent. This challenge remains, and aid agencies still struggle to maintain adequate operational access when working under politically constrained conditions. As humanitarian minimum standards, such as those advocated by the Sphere Project, acquire increasing global acceptance, these agencies also will be charged to demonstrate effectiveness and to ensure accountability, even in the complex and constrained climate of war and civil instability. To illustrate the challenges in negotiating access and ensuring adherence to humanitarian standards in the setting of political instability, this discussion examines the case of US non-governmental organizations (NGOs) attempting to operate in North Korea. As in other contexts, the quandary facing the humanitarian community in North Korea has mirrored national discourse regarding diplomatic engagement. Historically, the US has declined official diplomatic relations with North Korea, due primarily to objections over nuclear arms proliferation. However, when the US State Department removed North Korea from the List of State Sponsors of Terror in October 2008, the prospect of diplomacy and political engagement was reaffirmed. 2 The same question debated by the US government has confronted the NGOs operating in North Korea: should the regime in North Korea be engaged? For US NGOs in North Korea, such a decision essentially has been a choice to maintain operations or to leave, since access to the North Korean people is facilitated solely through the country's regime. Many US NGOs have been increasingly challenged by this question of engagement as the need for foreign humanitarian assistance has gained urgency in North Korea. Following an agricultural crisis, the elimination of critical partners for subsidized energy and trade, the death of a revered leader of 40 years, and, in the mid-1990s, a series of disasters related to natural hazards , North Korea has turned increasingly to the support of foreign humanitarian assistance. 3,4 The health sector has been particularly debilitated, with the collapse of the domestic pharmaceutical industry, increasing numbers of hospital …