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Elisabeth Rosenthal, a New York Times correspondent in Beijing and a physician, visited North Korea Feb. 6-10 with AmeriCares, a private, United States-based relief organization that was inspecting the use of aid it had already provided to North Korea. Two days after Dr. Rosenthal arrived, North Korean authorities told her that she could not work as a reporter during the trip. She said she could not continue the visit under those circumstances, and later left the country. Special Report • A View of North Korea's Famished Children (1997) 

PYONGSONG, North Korea — In the dim light of their frigid ward at the South Pyongan Provincial Children's Hospital, Kim Yuk and Kwang Sun listlessly fingered the small colored blocks that had been placed on their bed. They were too weak to be interested and too cold to come out from under their thick red covers anyway. It was 10 below outside, and a pot-bellied stove provided the room's only heat.

So they huddled, side by side, in deep layers of tattered sweaters under striped hospital pajamas, sharing both a bed and a miserable fate.
Though 12, the boys were the size of 8- or 9-year-olds, because for too many years they had had too little to eat. But this winter they are suffering life-threatening malnutrition, after coming down with a seemingly minor ailment, diarrhea, that their weakened bodies could not withstand. As with the six other children in their cramped, cement-walled room, their eyes peer out of hollow sockets, their arms protrude like kindling out of sleeves, scabs cover their skin, they are losing their hair.

And even this major hospital has little to give them, after a record poor harvest, during North Korea's coldest winter in 50 years.

"We are using things like antibiotics and painkillers, but on a very small scale due to the shortages," said Dr. Soh Hun Chul, the hospital's director, whose long white coat covered a pin of the late "Great Leader," Kim Il Sung, worn by all North Koreans. "We have lots of patients suffering from various diseases, but do not have enough medicine or equipment or food to properly treat them." 

After nearly a decade of crisis, the human tragedy in North Korea continues to outpace and outwit relief efforts. North Koreans are less hungry than during the worst food shortages, in 1997, thanks in large part to international aid, United Nations officials say. But the ongoing deterioration of the country's infrastructure — particularly its health and sanitation systems and its energy supply — has left many North Koreans in a continued downward spiral.

"It's not enough to give food, if hospitals have no medicines and the water supply is contaminated," said David Morton, United Nations coordinator in Pyongyang, the capital. "Malnutrition in Korea is a combination of shortage of food, breakdown of the health system and poor water supply. People who are weakened by years of hunger get sick very easily and are very vulnerable."

A recent trip with AmeriCares, the private, United States-based relief organization in North Korea to inspect the progress of its aid projects in hospitals and orphanages in and around Pyongyang was filled with scenes and tales of deprivation like these:
A neck operation being done under local anesthesia because the medicines required for general anesthesia were in short supply. 
A crowded patients' ward so cold that ice formed on the floor after it was mopped. 
Doctors forced to hammer out their own operating tools in a backyard metal shop.
A teenage boy whose broken leg was immobilized with planks of wood and strips of gauze because there was no casting material. 

The trip in early February was planned and chaperoned by representatives of the North Korean government, and no photographs were permitted. But the evidence of dire health conditions was bolstered by interviews with foreign aid workers and medical experts who travel extensively in North Korea — driving their vehicles through rivers because there is no way to repair bridges and staying in hotels without heat or running water.

"The health sector has just collapsed," said one aid worker, who like most spoke on condition of anonymity. "You probably have more in your home medicine chest than some county hospitals here have."

Mr. Morton, of the United Nations, said schools, hospitals and clinics all contain what the Korean government calls "weak children," children who have been chronically underfed. A nutritional survey by United Nations experts in 1998 found that 63 percent of North Korean children were stunted — or too small for their age — a result of long-term undernourishment that experts worry will impair the intellectual development of an entire generation.

While most foreigners who work here agree that cases of acute malnutrition are rarer now than they were four years ago, some said there appeared to be a recent surge with the unusually cold winter. And they worry that malnutrition is likely to worsen this spring, because last fall's drought-plagued rice crop was down 30 percent from 1999. Food supplies meant to tide people over through this poor harvest are already running out. 

"We give people subsistence — it's not a complete diet — so people slowly get more and more run down," one foreign expert said. "Reported malnutrition is probably artificially low since we all see these `weak kids' when we go to hospitals. And there's got to be high mortality this winter. It's simple logic: There's not enough food, no health care, and it's been very, very cold." 

Until North Korea went into economic free fall in the early 1990's, all citizens received the staples of life — food, housing, clothing, jobs and medical care — free from the government. Food was meted out each week through a national distribution system. Everyone was assigned a primary care doctor in a well-organized health system that ranged from village clinics to national referral centers. 

Only the shell of that system survives. North Korean officials and doctors date their problems to the "natural calamities" — flood and droughts — of the mid-90's. But that phrase is partly a euphemism for a deeper blow to the economy: with the fall of the Soviet Union in 1991, North Korea lost its main trading partner and biggest benefactor.

Immediately, people stopped getting enough to eat. Then the nation slowly spent down its accumulated stockpiles, its scant energy resources and its infrastructure to a point where there is little left.

Pump irrigation systems — crucial to farming — sat idle for lack of fuel. Commodities like spare tires, X- ray film and antibiotics were used up and could not be replaced. Factories slowed or halted production, lacking power and raw materials. There was no foreign currency for imports.
The state-run health system was particularly hard hit.

"We have many needs now," said Dr. Li Yong Chun, deputy director of the People's Tae Dong Gang District Hospital in Pyongyang. "Sure we have pharmaceutical factories, but because of the lack of, well, everything — raw materials, electricity, transport — they don't run in full."

Five years into North Korea's "food emergency," many experts say, food shortages, though still very serious, are no longer the country's most pressing problem. International aid groups now help feed 8 million of its 20 million people. And by now, many North Koreans have found ways to supplement that aid: raising their own chickens and vegetables, or buying food in the private farmer's markets that the government increasingly tolerates.

But personal enterprise cannot provide clean water, heat and health care, which are supplied exclusively by the state. 

Said a foreign medical expert: "You have a socialist health system where everything used to come from the state, and now the state is bankrupt. So what do you do? It's not like there's a private market where people can go buy medicines."

He said doctors had died of radiation sickness because, lacking X-ray film, they stand next to patients undergoing tests to check results on a fluoroscopy screen. In some rural areas, hospitals are growing cotton to make bandages, he said.

Some hospitals have received supplies from foreign aid groups. The International Red Cross, for example, supplies a number of county- level hospitals, and AmeriCares provides pharmaceuticals to hospitals in and around Pyongyang. The United States-based Eugene Bell Foundation supports the country's tuberculosis treatment program, and doctors in the far north get some medications smuggled in from China. But Mr. Morton said medical assistance had fallen well short of needs.

Doctors say lower-level hospitals and clinics are generally worse off, with little more than traditional herbal medicines at their disposal. Pyongyang has been spared the worst deprivation, they say, both in terms of food and health care.

But even the capital is obviously running at three-quarters speed. Stores have few goods. Rooms are barely heated, and lights are dimmed. And sprawling Kim Il Sung University Hospital, the country's best, has fallen on hard times.

Its exterior is bedecked with huge portraits of Kim Il Sung and of his son, the current leader, Kim Jong Il. Inside, pharmacists wear mittens as they compound medicines with mortars and pestles, and patients in thick jackets pad like ghosts through cavernous, unlit halls. 

On a recent morning's tour, the only warm place in the building was a suite of operating rooms, which nonetheless had the feel of a field hospital, with blood pressure being monitored by hand during surgery and IV fluid dripping into patients' arms from sterilized soda bottles. Scant supplies of general anesthesia were hoarded for only the most serious cases, surgeons said. 

"We have treatment plans, but we have trouble with procurement," said Dr. Ryu Hwan Su, a surgeon and the hospital's deputy director.
Doctors in the capital said they relied heavily on herbal medicines, though they did not consider them very effective.

At Tae Dong Gang District Hospital in Pyongyang, 15-month-old Li Pongmi, who coughed noisily in a carrier on her mother's back, had just been diagnosed with pneumonia. It was a typical examining room scene, except that everyone was fully bundled: doctor in an overcoat and mother wearing a padded jacket, her head swathed in a thick scarf.

The little girl would not be hospitalized for her illness; it was too cold for that. And although she was given an injection of penicillin, she would not complete the normal 10-day course. "First we give Western medicines for a little while, and then, as patients start to recover, we switch to herbal medicines," said Dr. Li Yong Chun, the hospital's deputy director. 

Despite such hardships, there is a certain normalcy to life in this isolated land. In Pyongyang, people line up at the bus stop and ride to work, even if their factory is not producing much. On the road northeast to Pyongsong, past one of many military checkpoints, the craggy hills are dotted with neat, white houses, and children, enjoying holidays for the Lunar New Year and Kim Jong Il's birthday, play on homemade sleds. 

But it is a normalcy easily upset, in a country with scant personal or institutional reserves. 

Earlier this winter, Kim Yuk, the 12-year-old patient in the South Pyongan Provincial Children's Hospital, was out there playing, too. Though clearly stunted, he said he had never been seriously ill before.

But then he came down with diarrhea, which tipped him over the edge. When he was admitted to the hospital in mid-January, his kidneys had shut down, his body was swollen, and his blood pressure was critically low. 
Digestive problems are common here, partly because so many people stretch their supplies of edible grains with inedible filler, like corn husks. Infectious diarrhea is a problem because the country has neither electricity nor chlorine to ensure clean water.

What would be a minor ailment in otherwise healthy children can turn life-threatening in the chronically undernourished like Kim Yuk.
Doctors say he needs more than 2,500 calories a day to recover. But Dr. Soh, the hospital director, said he has only been able to provide meals of rice and porridge, supplemented by snacks he brings from home.

"The hospital does its best to help, but it's really not enough," he said.
Likewise, he said, for patients who should have operations but will not, except in emergencies — because of the lack of anesthesia, electricity, sterilization equipment and decent surgical tools. And likewise for the tens if not hundreds of thousands of North Koreans who suffer from active tuberculosis, but will not be treated.

"They don't die here like they did in Ethiopia," one medical expert said, referring to the high toll from starvation there several years ago. "They get some food. They share. But then they get a respiratory illness or diarrhea or they need minor surgery — which can't be done properly because there are no antibiotics — and then they die."