Is North Korea hiding a bigger problem behind its Covid-19 outbreak?

"North Koreans call them rubber band statistics," he said, in a nod toward Pyongyang's flexibility with the truth. "It's hard even for North Korea to know its own numbers."

He speaks with some authority. Choi was a doctor for more than 10 years in North Korea, specializing in infectious diseases before he fled his home country in 2011.

He can remember the SARS outbreak of 2002-2004, when he says hundreds of people in the northeastern city of Chongjin, where he was working, began dying after reporting "cold or flu-like symptoms."

Doctors like Choi could only privately suspect SARS was to blame. North Korea had no ability to test for the disease, so officially it recorded zero infections. Its neighbor China reported more than 5,000 cases and hundreds of deaths.

Choi can also remember dealing with a nationwide measles outbreak in 2006, armed only with a thermometer; and a 2009 flu pandemic in which even "more people died than during SARS" -- a situation made worse by an acute shortage of medicine.

In previous epidemics, Choi explains, there was never an incentive for local officials to travel house to house to accurately count cases -- they had no masks or gloves and they figured statistics would be massaged by the regime to suit its needs.

He assumes little has changed since he left and that history, if not exactly repeating itself, is at least rhyming.

What's North Korea hiding?

As with past outbreaks of disease in North Korea, one of the biggest concerns surrounding the country's Covid outbreak is that Pyongyang's penchant for secrecy makes it hard to accurately gauge its severity.

International NGOs and most foreign embassies have long vacated the country and tightly sealed borders mean access is impossible, making the accounts of defectors like Choi all the more important.

Many were surprised by Pyongyang's decision in May to admit it was dealing with an outbreak, even if the accuracy of its statements since have faced skepticism. Early on, leader Kim Jong Un had described the outbreak as the "greatest turmoil" ever to befall the country. Two months and millions of suspected cases later, he claimed a "shining success" in stopping the disease in its tracks.

The incredibly low official death toll the country has reported inevitably raises suspicions that Pyongyang is trying to hide a bigger problem.

"I have some questions," South Korea's Unification Minister Kwon Young-se said pointedly last week, noting the story being peddled by the North's state-run media contrasted sharply to the experience of the rest of the world.

New Covid variants, cholera?

The biggest fear initially was that an outbreak in an unvaccinated, malnourished population with primitive health care would be catastrophic.

Tomas Ojea Quintana, UN Special Rapporteur for human rights in North Korea, said knowing the scale of the outbreak is impossible at the moment -- though he had heard unconfirmed reports of deaths among the elderly and malnourished children.

"At least in my position, I am not able to contrast this fear that we had at the beginning of 2020 about the catastrophic consequences of Covid in (North Korea) and its current situation."

There are also fears that new, possibly more virulent, variants could emerge from unchecked transmission through North Korea's population of about 25 million.

Dr. Kee B. Park, an American neurosurgeon who until the pandemic started had been visiting North Korea twice a year to work alongside North Korean counterparts, training them and performing surgeries, said the country seemed unwilling to share information and this was "not good for them (and) it's not good for the rest of the world."

"We have to share information on any kind of new changes in the characteristics of the virus, for instance, mutations, right," he said.

"We need to be aware of the fact that high replication can lead to new variants. The only way to detect that is to share information with each other."

In June, North Korea said it was experiencing an outbreak of an unidentified intestinal disease in South Hwanghae Province, about 75 miles (120 kilometers) south of the capital Pyongyang.

At the very least, the announcement demonstrated the country's vulnerability to disease outbreaks and its lack of medicines.

Park believes North Korea is probably dealing with an outbreak of typhoid fever or cholera.

"Somewhere like North Korea, you can expect high rates of infectious diseases. In fact, for children under 5 years of age, diarrheal diseases are the number one killer."

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