NORTH KOREA: A railway accident can happen anywhere. The difference, in North Korea, is that its health and emergency services, which might have been able to acquit themselves relatively well some 15 years ago, have now deteriorated to such an extent that, according to a senior UN official, outside the capital Pyongyang they are virtually non-existent.
In an interview given in Pyongyang before the Ryongchon railway disaster, Eigil Sorensen, the head of the UN's World Health Organisation programme office there, said that health services outside the capital were "in crisis".
He said: "Their ability to handle severe diseases in children, accidents or emergencies, is very limited."
The chronic decline of the North Korean economy since the collapse of the old Soviet-led socialist trading bloc in 1990 has left much of the country without electricity.
Infrastructure is so dilapidated that water pumps in hospitals have mostly broken down and, with no spare parts or money to repair or replace them, this has meant that "in reality, very few hospitals have running water", Dr Sorensen said.
North Korea is a notoriously secretive country but access for the UN and foreign organisations has been improving over the last few years, especially since the worst years of the great famine in 1995-99 in which anywhere between 200,000 and three million people are believed to have died.
Still, said Dr Sorensen, the culture of secrecy persists, which means that full access to all hospitals, especially in areas with the greatest difficulties, is limited. "Obviously people are suffering and dying because of that, but we don't see those patients."
A Chinese building contractor, who had been installing new windows in a provincial town and who asked not to be named, told of appalling conditions in the hospital. He said that windows were often broken and just covered in plastic sheeting, that there were only a couple of hours of electricity a day and that patients were kept warm by burning corn cobs in stoves.
Healthcare, according to Dr Sorensen, was not a priority for the government and neither was it for foreign donors, who, while they might give emergency food aid, were not as generous with anything that smacked of straight development aid. The reason for this, he explained, is that while many foreign countries do not want North Korea to collapse, they do not want to do anything either which could be interpreted as supporting the current, conservative, communist regime.
According to Dr Sorensen, North Korean officials are well aware of just how vulnerable they are. At the height of the SARS crisis last year, North Korea basically just closed. The border to China was shut. Even now, there are only between six and eight scheduled international flights a week in and out of the country and the main way in is via Beijing.
During the SARS crisis that flight was suspended and so, from last April to July, virtually the access to the country was by getting on the occasional flight to Siberia.
The news that two patients have just died in China from SARS is now likely to be received with the utmost alarm in Pyongyang.
Apart from the lack of drugs, equipment and general dilapidation in North Korea's hospitals, it faces another acute problem. Although North Korea has a relatively high number of doctors per head of population compared to countries with a similar background, like China or Vietnam, the country's isolation has meant, says Dr Sorensen, that doctors "practice medicine like they did 30, 40 or 50 years ago in other countries. People here are trying their best with the resources they have but they are also suffering from very little exposure to trends in healthcare. In 1997 they had never heard of 'paracetamol'. It was unknown to medical doctors."
Dr Sorensen's concerns are echoed by Pierrette Vu Thi of UNICEF. According to her, large numbers of schools need rehabilitation and "outside of Pyongyang schools are very cold and the electricity supply is erratic".
This means, she says, that, "especially in the north east of the country, where the population is most vulnerable, school attendance goes down because of heating problems".
On the bright side, however, North Korea has a literacy rate of some 99 per cent, but raising the same concerns as Dr Sorensen, Ms Vu Thi, said: "We have to build the capacity of our government counterparts to new ideas and new approaches."
Much of the content and form of the North Korean school curriculum, it seems, has not been updated since the end of the Korean War, more than half a century ago.
One reason why the North Korean government has been slow to release information about the disaster may well be due to the same problem. That is to say that while it is clear that officials have been told recently that they should give more information out to the media, they simply have no experience of dealing with the press and do not know what are the limits of openness and how much information they can release.
Admitting to problems, and especially publicly admitting that foreign aid is necessary, also runs into an ideological problem. It appears to undermine the country's ideological underpinning, which stands parallel to communism, which is "Juche" or self-reliance.
In fact North Korea is somewhat less self-reliant than officials like to admit. Today the UN's World Food Programme helps feed some 6.5 million out of a total population of 23 million. Other aid organisations are present, including Ireland's Concern.