Of North Koreans and Parasitic Infections


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No, not this “Parasite.” (CJ Entertainment, 2019)

Content Warning for images and descriptions of violence, human remains, extreme bodies, and parasites.

On November 17, 2017, the 25 year old Oh Chong-song,son of a North Korean major general and one of the elite soldiers who patrol the Joint Security Area between North and South Korea crashed the jeep he was driving having lost control and careened past a checkpoint. Fearing he would face execution for his mistake he took off running towards the South Korean border drawing fire from his soon to be erstwhile comrades and was struck five times before collapsing. Still under threat of fire, South Korean soldiers were able to shimmy up to his unconscious form and drag him to safety.

Standing 5'7" (160 cm) tall and weighing just a bit more than 132 lbs (60 kg), Oh was in better health, of greater stature, and had access to more and better quality food than the majority of North Koreans who on average tend to stand about five inches shorter than their South Korean counterparts and suffer extreme chronic malnutrition. Yet, in the inevitable surgery which followed his escape — Oh was said to have lost more than half his blood — doctors removed from his intestines a multitude of parasites including roundworms some of which had grown to a length of 11 in (23 cm).

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Severely malnourished North Korean soldiers (Kim Dong-cheol, ASIAPRESS, 2011)

In a country where soldiers are not always or even usually provided with rations and where medical doctors do not see more than a single dollar in pay for a day’s work Oh was at least receiving regular meals. Despite being considered an elite soldier he did not have much muscle, but he was at least within a healthy BMI.

However, this doesn’t really mean he wasn’t dangerously malnourished.

North Korea spends the majority of it’s GDP on its military in particular its nuclear program. Despite having a mountainous and rocky terrain somewhat hostile to agriculture the government does not produce or provide chemical fertilizer. Instead, North Koreans — including North Korean children — are expected to fulfil a quota of 100kg (220 lbs) of animal and human faeces each year. The faeces is not treated to remove parasites, it is simply distributed to farmers who use it to fertilize crops.

Families will argue and fight over who gets to pick up the dog’s poop and parents will chastise their children if they pooped away from home. Complicating the matter is the fact that North Koreans tend to be so malnourished that they do not often poop.

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Please PLEASE don’t make me explain why you shouldn’t do this.

But all this casual handling of untreated faeces and growing plants which in some cases may only be rinsed before eating, in human and animal dung means that North Koreas are at incredible risk for parasitic infections. Maybe in some species of fish a parasitic infection is somehow beneficial, but in humans it is categorically bad regardless of what the old-timey ads may tell you.

In the best-case scenario parasites will live in your intestines off of nutrients you are ingesting before they can be absorbed through your intestinal wall. If you are getting enough food this might be less of a problem, but it will still make it difficult for you to get a good balance of nutrients and it can be a bit painful. But this is not the worst of it. Some parasites will travel outside of your intestine and set up house in other areas of your body including your heart. You really need your heart. It’s kind of important.

But particularly in malnourished and chronically malnourished people parasites do cause the added issue of making it near impossible for that individual to eat enough to survive. It is pretty common archaeologically speaking to find individuals with what’s called cribra orbitalia. This is basically exostosis in the orbital or benign bony outgrowth in the eye sockets. In severe cases you’ll see this same porous exostosis all over the cranium.

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This is actually pretty extreme. We rank cribra orbitalia according to Stuart-Macadam (1991) and without looking it up I’m pretty sure this is the worst you can have on their scale. (Image)

What’s happening is the individual had a severe form of haemolytic anaemia meaning their red blood cells were being destroyed faster than they could be produced. Their body tried to grow more marrow to produce more blood cells but ran out of space and thereby ended up creating these outgrowths of bone usually in the orbitals and sometimes on the front of the cranium and — according to some literature — on the epiphyses of long bones.

The reason this is happening can be malaria, or a genetic anaemia like thalassemia, but it can also be a severe deficiency in B12. (There was some argument that this kind of lesion could be caused by iron deficiency but for the most part it’s agreed to be due to haemolytic anaemia.) Most people — even vegans — in the Western World don’t need to worry too much about this. B12 is found in abundance in animal protein so if you eat meat at all, or eggs or cheese, you’re probably fine. Vegans have a weird supplement thing that they (incorrectly) think is delicious and that weird supplement thing is crammed with B12 because if it weren’t vegans would die. But if you don’t have the weird vegan cheese, and you don’t usually have meat, and you don’t even know what cheese is, and you get fish but very rarely, and only sometimes can you have eggs, then B12 is going to be an issue for you.

Again, archaeologically speaking there’s basically two situations in which rates and severity of cribra orbitalia spike and that’s when a population starts farming and if there’s a high incidence of parasites found in latrines. (Or standing pools of water, but as usual, we haven’t got the time.) Sometimes these actually aren’t completely related. Because we usually treat our fertilizer or use chemical fertilizer most populations are only likely to get parasitic infections from ingesting undercooked or raw fish or meat. So it’s totally possible for archaeological populations to have picked up their parasites from fish they ate. In fact, malaria itself is a parasitic infection so you don’t even have to eat something bad to get a parasite. But, if a population is lowering their intake of animal protein because they’re relying more on grains which they grow in fields fertilized with dung, their rates of parasite driven malnutrition are likely going to increase.

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I’m sorry. I can’t make this less gross. (CDC)

I am massively simplifying here and there’s quite a bit more to consider when talking about malnutrition and foodways for past populations, but agriculture was not really nutritionally our best move as a species. Yes, it contributed to a population boom and the potential for diversification of labour so there absolutely were advantageous trade-offs, but skeletally there are pretty consistent signs of malnutrition particularly at the outset.

Standing only a bit taller than me, Oh is considered quite tall by North Korean standards, but only average among South Koreans. North and South Koreans remain very closely related with familial links across the border dating only since the Korean War. All things being equal their populations should be skeletally similar.

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Harris lines in a child’s distal femur and proximal tibia. (Radiopaedia)

And yet they’re not. North Koreans are chronically malnourished in part because they are not provided with food or really allowed to keep or sell the food they produce and in part because of the horrifically unhygienic conditions they are forced to endure. When children in particular are poorly nourished their bodies naturally reroute any resources to their hearts, brains, and vital organs. If at any point there are enough resources to allow for it, long bone diaphyses will grow and enamel will be laid down on permanent teeth forming in their maxillae and mandibles. Cessation of bone growth and subsequent start up thereafter creates what are called Harris lines and in teeth intermittent cessation in enamel formation causes what is called linear enamel hypoplasia which are basically linear dents in the teeth. Cortices will be thin, trabecular bone may be sparse, and any time an additional stressor is applied — for instance a family argument or a cut or scrape or perhaps something more serious like watching an execution or infectious disease — their bodies will take the scarce resources away from growing bones and focus on that infection or that psychological stress the child is dealing with.

After a time, the epiphyses start fusing to the diaphysis of each long bone and that individual has more or less run out of time to grow. (There can be catch-up growth in late adolescence but this will not make up for cortical thickness and can cause additional issues as valuable resources are routed towards growth and away from other bodily functions.) Short people who get enough to eat as children are just short, but in a population like North Korea where they should have been growing considerably taller not only are they failing to achieve the height they’re genetically predisposed for, but they will have life-long health issues thereafter even if — like Oh Chong-song — they escape the regime and get on a healthy diet.

Oh had many of his parasites removed during surgery and likely was given medication to clean out any remaining eggs or smaller worms that the surgeon missed. He is also presumably eating a reasonable and regular diet including grains, vegetables, and meat. He may have put on some weight and because his father was high up in the regime Oh Chong-song may have escaped some of the more severe health complications that North Koreans from the middle and lower castes have.

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Pictured: why I don’t treat living patients. (Image source)

At its most severe North Koreans in prison camps will pick through faeces for undigested grains and catch rats to eat. This includes children born in such camps.

If however, Oh had come from the middle class or lower he would likely have lines on his teeth where enamel failed to form in his childhood, he would be considerably shorter, he might have cardiovascular issues and would be at higher risk of them later in life, and once he started on a normal diet he would be at higher risk for Type II diabetes.

Oh seems to believe that he had parasites because he had a better diet than most North Koreans. This is probably inaccurate. The parasites may have had a better chance at survival and this is possibly why he had such big worms found in his gut, but unfortunately, extreme malnutrition does not really inoculate a person against parasitic infection. Parasitic infection complicates malnutrition, but it is likely that the many starving individuals in North Korea also regularly contract parasitic infections which make their malnutrition even worse.

As fascinating as it is to see how an extremely stressed population might behave in vivo particularly using agricultural techniques which predate modern hygienic standards and medicine, this is a humanitarian nightmare. There’s really no viable reason that North Koreans must live in such terrible conditions. The regime could afford to better feed their population, it could simply provide chemical fertilizers which would instantly improve the health of the population or it could provide reasonable healthcare. Instead it spends all its money on the nuclear program and terrorizes and starves its population into submission.

Doctor of Palaeopathology, rage-prone optimist, stealth berserker, opera enthusiast, and insatiable consumer of academic journals.

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