In a report submitted to the U.N. in 2021, North Korea itself reported a “lack of capacity of health personnel, low technical foundation of pharmaceutical and medical appliance plants and shortage of essential medicines.” Pharmacies also reportedly lack medical supplies and storage facilities. Hospitals also suffer from poor electricity supply and lack of heating.

Given these, a massive outbreak in North Korea would be “dangerous” and “potentially destabilizing,” according to J. Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies in Washington. He predicts high fatalities, with a mortality rate as high as 1%, and possibly half-a-million to a million cases of severe illness.

The median age of North Koreans is around 35, which may somewhat mitigate the risk of death. But the country “has a very fragmented and weak health infrastructure which will be easily overwhelmed and they do not have medical stockpiles that are of any use in this situation,” Morrison says.