North Koreans with disabilities may face disproportionate risk due to efforts to curtail the country's weapons of mass destruction programs.
Some humanitarian aid groups providing medical, educational and material support to people with physical, sensory and other developmental impairments say United Nations sanctions, as well as the Trump administration's "maximum pressure" campaign imposed on Pyongyang for its nuclear and ballistic missile tests, are limiting their ability to carry-out work in North Korea.
Amid those restrictions, some non-governmental organizations (NGOs) are abandoning their programs altogether.
Multiple sources involved in aid work tell VOA that Humanity & Inclusion (HI) is ceasing its North Korea operations. The French/Belgian organization, also known as Handicap International, has been active in the country since 2001 and works in conjunction with the state-run Korean Federation for the Protection of the Disabled, according to the non-profit's website.
HI declined to respond to VOA's request for confirmation.
North Korea's opacity and the reluctance of many NGOs to publicly discuss their work there make it difficult for outside observers to obtain a full picture of the situation.
But, Nazanin Zadeh-Cummings, who lectures in humanitarian studies at Deakin University in Melbourne, Australia, says the "detrimental impact of sanctions" is primarily responsible for the departure of international organizations, like HI, from North Korea.
She explains that while humanitarian activity in North Korea is permitted under the sanctions, the lengthy process of applying for exemptions from member states and the UN Sanctions Committee as well as blocks on financial transactions lead to the erosion of partnerships that these organizations have spent years building with Pyongyang.
"It's really a tragedy," Zadeh-Cummings says. "Because of time delays, uncertainty and difficulties in getting sanctions exemptions, those decades of trust and relations are being threatened."
Among the relief agencies that have pulled-out or suspended work in North Korea are Finland's Fida International, which closed its food security program earlier this year, and the Britain-based charity Save the Children, which left the country in 2017. Both organizations say the pressure brought on by sanctions forced their decisions.
Zadeh-Cummings notes the closure of programs that benefit the disabled could be a lost opportunity. She says that despite North Korea's reputation as one of the world's worst human rights abusers, the regime "shows a willingness to engage" with the international community over the creation of such initiatives, which have gone from "non-existent to a space for collaboration" with aid groups in the past several years.
"The people on the receiving end of this aid are the ones who are losing out," due to the international sanctions, she adds.
The sanctions further complicate many NGOs' ability to provide support for North Korea's disabled due to a "dual use" ban on metallic objects because of concern these could end up in the hands of the country's military. In turn, this measure could prohibit many medical supplies and adaptive equipment from entering North Korea, unless an import license and waiver are obtained, which some humanitarians say could take many months or years, if not at all.
"I can't send wheelchairs, crutches or canes because they all have metal in them," says Sue Kinsler, whose California-based Kinsler Foundation has supported North Korean schools for the blind and has helped disabled athletes compete in recent Paralympics and other sporting events.
She says her charity, which relies on small donations from churches in South Korea and the U.S., has not been able to raise sufficient funds or collect many donations in recent years.
"They all stopped helping me because of the sanctions," she says. "They're afraid of breaking the rules."
Kinsler, who says she used to visit North Korea several times a year, adds that she hasn't returned since Washington banned U.S. citizens from traveling to the country following the death of tourist Otto Warmbier in 2017.
Some other American aid workers have obtained permits to enter North Korea to carry-out relief work.
Dr. Kee Park, director of DPRK Programs at the Korean American Medical Association, says he travels to North Korea twice a year and performs surgeries with local physicians. DPRK stands for Democratic People's Republic of Korea, the North's official name.
Park, who lectures at Harvard and co-authored the recent report The Human Costs and Gendered Impact of Sanctions on North Korea, says the difficulty in "navigating the regulatory hurdles" required to obtain permission to transport even the most basic of medical devices to North Korea could mean many patients will become permanently disabled.
"If they have an injury and cannot obtain surgical care in a timely fashion they might end up with a disability," he says, adding that sanctions could prevent performance of "simple operations" for disabling conditions such as cleft pallet, clubbed foot and cataracts.
Park says that despite the lack of new surgical instruments, North Korean doctors are "masters at maximizing the utility of their medical supplies."
"They reuse as much as possible until things become unusable," he says.
North Korea has given Washington an end of year deadline to drop what Pyongyang calls a "hostile policy" in order to resume stalled denuclearization talks. Some observers say the North wants relief from unilateral U.S. sanctions that have reduced its capacity to earn foreign sources of income - an indication that these measures are having their intended effect.
Sung-Yoon Lee, a Korea expert at The Fletcher School at Tufts University, writes in an email to VOA that "targeted financial sanctions are a potent and fine-tuned, non-lethal instrument of coercion."
Lee notes that while sanctions are not a "perfect instrument", he argues that humanitarian concern should instead focus on the Kim regime's "perverse priorities" as the root cause of the North Korean people's "misery and hunger."
"There will invariably be negative trickle down effects on the innocent people and in procedural aspects related to the delivery of aid," Lee writes.
Andray Abrahamian, a visiting scholar at George Mason University's Incheon, South Korea campus, agrees that North Korea is "unable or unwilling" to care for many of its citizens, including people with disabilities, and so has largely outsourced this responsibility to international aid groups.
But Abrahamian, who previously worked for a North Korea-focused NGO, says the livelihood of this already disadvantaged population will continue to decline if recipients of humanitarian support are seen as "collateral damage."
"The further you are away from political power the more vulnerable you are to sanctions-imposed scarcity," he says.