Childhood Immunization and North Korean Refugees in China

China risks creating a permanent underclass—and a public health catastrophe
June 27, 2017 7:00 AM

While concerns over geopolitical tensions understandably dominate current attention to the Korean peninsula, a humanitarian crisis continues to fester. I was reminded of this when I stumbled across a paper, “Childhood immunizations in China: disparities in health care access in children born to North Korean refugees,” by Hyun Jung Chung, Seung Hyun Han, Hyerang Kim, and Julia Finkelstein in the journal International Health and Human Rights. The bottom line is unsurprising: refugee children exhibit markedly lower rates of immunization than Chinese, and even internal migrant Chinese peers. But the authors uncover some subtleties with potentially disturbing implications in reaching this conclusion.

The study is based on a survey done in 2010 in the Yanbian Autonomous Region. The authors surveyed 91 caregivers of refugee children and then matched their survey data to existing data on Chinese permanent resident and migrant populations. While there are always sample selection issues in surveys of this sort, the method used by Chung, Han, Kim, and Finkelstein would seem to generate a random, or at least quasi-random, representative sample of the underlying population.

Universal immunization has been a goal of Chinese policymakers and with special programs introduced to target the possibly hard-to-reach internal migrant community, the proportion of immunized infants is roughly 99 percent for the non-migrant population, over 90 percent for the babies of migrants.

The North Korean refugee children are typically the product of relationships between North Korean women and Chinese men. Demographic data collected in the survey document that these households are generally poor with fathers having elementary school or no formal education. Not only are these children from socio-economically disadvantaged backgrounds, they are technically stateless and not eligible for these government programs. Immunizations for this population are typically organized by churches and NGOs. It is no surprise that their immunization rates are lower, markedly lower in some cases, than their Chinese peers.

(The BCG vaccination for tuberculosis is the single exception—the immunization rates for the North Korean refugee children are not significantly lower than for either Chinese comparator group. Some speculation as to why this case was different would have been welcome.)   

The government risks not only creating a permanent underclass, but fostering conditions amenable to the re-emergence of deadly communicable diseases.

Statelessness is not the whole story though. Chung, Han, Kim, and Finkelstein found that the father’s age, having a sibling, and the mother having a history of miscarriage also mattered. Father’s age and educational attainment, and having a sibling have been found to influence immunization rates in past studies. Older and less educated fathers are associated with lower rates of immunization, as is having a sibling. Interestingly, a mother’s history of miscarriage is associated with higher rates of immunization, presumably due to effects on knowledge and/or attitudes regarding available health services, as well as treatment-seeking behavior.

What emerges is a portrait of a socio-economically disadvantaged community which due to policy faces legal challenges in accessing health care. (The parallels to the contemporary US go without saying.) Problems accessing health care for this sub-population means potentially greater later life health problems, difficulties in employment, etc. and the creation of a self-reinforcing negative feedback loop. Chung, Han, Kim, and Finkelstein, without substantiation, cite an estimate of possibly 10,000 to 50,000 such stateless children born each year. This range strikes me as very high. But if one takes it at face value, it suggests that by not vaccinating a significant pool of refugee children for maladies such as polio and rubella, the government risks not only creating a permanent underclass, but fostering conditions amenable to the re-emergence of deadly communicable diseases.

And that’s even without throwing vaccination conspiracy theorists into the mix. 


Kumudini Sandesha


Measles, also known as rubeola, is a highly infectious disease. It’s caused by a virus, and can be prevented by effective vaccination. The adult form is more severe than when children acquire it, and the infected adults would end up feeling way worse.

Most people get better within 2 weeks. But measles can sometimes cause dangerous problems, such as lung infection (pneumonia) or brain swelling (encephalitis). In rare cases, it can even cause seizures or meningitis.


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