In a pediatric hospital in North Korea's most productive farming province, children lay two to a bed. All showed signs of severe malnutrition: skin infections, patchy hair, listless apathy.
"Their mothers have to bring them here on bicycles," said duty doctor Jang Kum Son in the Yellow Sea port city of Haeju. "We used to have an ambulance but it's completely broken down. One mother traveled 72 kilometers (45 miles). By the time they get here, it's often too late."
It's also getting late for North Korea to get the massive amount of food aid it claims to need before the harsh winter sets in. The country's dysfunctional food-distribution system, rising global commodities prices and sanctions imposed over Pyongyang's nuclear and missile programs had contributed to what appears to be a hunger crisis in the North, even before devastating summer floods and typhoons compounded the emergency.
The regime's appeals for massive food aid have gone mostly unanswered by a skeptical international community. Only 30 percent of a United Nations food aid target for North Korea has been met so far. The United States and South Korea, the two biggest donors before sanctions, have said they won't resume aid until they are satisfied the military-led communist regime won't divert the aid for its own uses and progress is made on disarmament talks.
South Korea also says the North is exaggerating the severity of its food crisis. Visiting scholars, tourists and charity workers have sent out conflicting views about it.
The U.N.'s Food and Agricultural Organization (FAO), for instance, said last month after visiting the North that "the damage was not so significant." Another U.N. body, the World Food Programme, which has a regular presence in the North, warned in March of growing hunger. The sharp divergence of views is one reason why the U.N.'s emergency relief coordinator will visit this month to assess the situation.
North Korea's Economy and Trade Information Center, part of the foreign trade ministry, invited Alertnet to see the extent of the crisis on a rare reporting trip to its rice bowl in South Hwanghae province in the southwest.
Alertnet, a humanitarian news service run by the Thomson Reuters Foundation which covers crises worldwide, saw evidence of alarming malnutrition and damaged crops, but also signs of some promise for the coming rice harvest.
Although tightly controlled by government officials, an Alertnet reporter and Reuters photographers and video journalists were able to conduct a week-long trip into the South Hwanghae region. The visit included rare access to collective farms, orphanages, hospitals, rural clinics, schools and nurseries.
The regime's motive in granting the access appears to be to amplify its food-aid appeals. North Korean officials at first asked Alertnet to reach out to its subscriber base to mobilize help--and at one point asked the Thomson Reuters Foundation for a donation. Alertnet declined, saying all it could do is visit and report on the situation.
The picture the regime presented in South Hwanghae was largely one of chronic hunger, dire healthcare, limited access to clean water and a collapsing food-rationing system, all under a command economy that has been in crisis since the collapse of the Soviet Union 20 years ago threw North Korea into isolation.
In one orphanage in Haeju, 28 children huddled together on the floor of a small clinic, singing "We have nothing to envy" -- an anthem to North Korea's longstanding policy of juche, or complete self-reliance, that has made this one of the most closed societies on earth.
Measurements taken of each child's mid-upper arm with color-coded plastic bracelets -- a standard test for malnutrition -- showed 12 were in the orange or red danger zones, meaning some could die without proper treatment.
Nutrition experts from Medecins Sans Frontieres (MSF), who accompanied AlertNet, found similar results among children at other institutions. But they stressed their findings were not statistically representative.
At an orphanage in Hwangju town, across the provincial border in North Hwanghae province, 11 of 12 children in the clinic were critically malnourished. They looked to be no more than three or four years old, but orphanage staff insisted they were eight, citing severe stunting due to malnutrition.
"I've never seen stunting like this before, not ever -- not even in Ethiopia," said Delphine Chedorge, deputy program manager of emergencies for MSF France.
In the orphanage's kitchen, the only food for the 736 children was maize and a thin soup made of onion and radish leaves. Cooks said they had no oil, sugar or protein -- vital ingredients for adequate nutrition.
"They've had to reduce the minimum height limit for the army by 2 cm," a Western aid worker in Pyongyang said, speaking of stunting.
North Koreans on average live 11 years less than South Koreans due mainly to malnutrition, according to U.N. health indicators.
Famine fears again?
In March, the World Food Programme (WFP) estimated that 6 million North Koreans needed food aid and a third of children were chronically malnourished or stunted. By contrast, the United Nations says 4 million people face a food crisis in Somalia.
The WFP's appeal inevitably raised the specter of the mid-1990s, when years of mismanaged farm policy and natural disasters resulted in famine that some estimates said killed as many as a million people. Nobody is saying this year is anything like that -- and South Korea has said it suspects Pyongyang of exaggerating the crisis.
North Korea has relied on food aid since the mid-1990s. Critics say Pyongyang spends most of what little hard currency it earns maintaining a million-strong army and developing nuclear weapons and missiles instead of feeding its millions of malnourished people.
A savage winter that froze seeds in the ground hit early crops even before this summer's floods. In South Hwanghae, the governing People's Committee said, the cold wiped out 65 percent of the province's barley, winter wheat and potato crops, which are sown in autumn and harvested in spring.
Between late June and early August, torrential rains, successive floods and two typhoons inundated southwestern and central provinces. Hardest hit were the plains of South Hwanghae, whose sprawling, collective farms are essential food providers in a mountainous nation where only a fifth of land is arable and the climate is harsh.
Typically, the province generates about a third of the country's total cereal supply, pumping wheat, maize and rice into the Public Distribution System, on which two-thirds of the population relies.
Last year, 16 of South Hwanghae's 22 counties produced a surplus, providing precious calories for people elsewhere, especially in towns and cities where chances to fish, forage and keep household gardens are limited. The summer storms destroyed 80 percent of the province's early maize harvest, the People's Committee said.
Those figures were impossible to verify.
AlertNet saw fields buried under mud and sand washed down from higher ground, as well as broken concrete bridges and collapsed school buildings and medical centers.
"The harvest is lost, and we'll just have to turn the ground over," said a senior official with the provincial Flood Damage Rehabilitation Committee. "We don't have any tractors so we'll do it by hand."
At Soa-Ri collective farm, which was hit three times by floods, about 100 families were living under Red Cross tarpaulins amid the buckled ruins of bungalow-style homes.
An enormous tree lay prone in the muck, snapped at its base by the force of flash floods, whose power and frequency have intensified in recent years due to rampant deforestation in a country where many still need firewood for cooking.
Jong Song Hui, 40, recalled how she was sleeping when her house started caving in, its mud bricks turned to mush by days of heavy rain. Woken by the crashing of timbers, she grabbed her two children and got out just in time.
"The only things I could save were the portraits of the Great Leaders," she said. She was referring to pictures of North Korea's founding father, Kim Il-Sung, and his now ruling son, Kim Jong-il, which adorn many walls in one of the world's most enduring personality cults. The elder Kim remains posthumously the formal head of state, proclaimed "eternal president" four years after his 1994 death.
The rains also destroyed Soa-Ri's clinic, which serves 4,790 people on the collective farm. "Living conditions are terrible," said the clinic's doctor, standing outside a dilapidated building that functioned as a substitute clinic.
"The water supply is heavily contaminated -- wells are polluted. So people are suffering diarrhea and digestive disorders. Also, it's getting colder, so people are getting pneumonia and bronchitis."
In Haeju, 40 percent of the city's 276,000 people were still without water due to damage to the mains system, forcing residents to trek 4 kilometers into the mountains to lug water from fresh streams, municipal officials said.
Teams of students and factory workers were digging to find the broken concrete pipes connecting Haeju with a reservoir almost 7 kilometers away. All the pipes would have to be replaced.
Soldiers guard cornfields
The U.N.'s top humanitarian official, Valerie Amos, will visit the country for the first time later this month to assess the country's food needs and how aid can be monitored to ensure it does go to those who need it most.
Experts have presented conflicting views about North Korea's harvests. Last week, Hiroyuki Konuma, the U.N. Food and Agriculture Organization's regional representative in Asia, said crop damage from the summer's extreme weather was "not so significant" after finishing a three-day trip to North Korea.
Ondine Ripka, a food security analyst with MSF France, said even minor natural disasters could have catastrophic consequences for vulnerable people.
"We did witness some damage in the fields," she said. "But we shouldn't forget that people are already living on the edge, and it takes very little to push them over into malnutrition."
Along pot-holed roads neatly planted with cosmos and asters, AlertNet saw acre after acre of brown, drooping cornstalks, suggesting some damage at least to South Hwanghae's maize crops.
Pak Su Dong, manager of the Soksa-Ri farm, held up a withered cob and pulled back the husk, revealing just a few yellow kernels inside.
"Since June, we had heavy rain for two months, so that's why the maize couldn't get enough nutrients to grow properly," he said. "We now expect to harvest only 15 percent of the maize output we had originally planned."
Despite the sorry-looking crops, soldiers were guarding many cornfields against raiders, keeping watch from wooden shelters with straw roofs.
Food and Nuclear diplomacy
Next April marks the 100th birthday of "Eternal President" Kim Il-sung, and skeptics accuse North Korea of hoarding food for the centennial celebrations.
South Korean officials say the North is stockpiling food ahead of a possible underground nuclear test, which would likely provoke another round of sanctions.
In August, the United States offered $900,000 in flood assistance that consisted largely of supplies such as plastic sheeting and tents, saying it carried less risk of diversion.
North Korea's closed society and fixation on weaponry have thrown up plenty of doubt over the years about its perennial food aid requests. Aid has often been intertwined with diplomacy over its nuclear and missile programs.
North Korea said in August, in the midst of its food aid appeals, it was willing to resume regional disarmament talks at an early date without preconditions.
North Korea in the past has won food aid pledges after resuming talks on its nuclear program, which have dragged on for much of the past decade. Pyongyang has conducted two nuclear tests, in October 2006 and May 2009, and is believed to have enough nuclear material for up to a dozen warheads.
South Korea halted shipments of food and fertilizer in early 2008 at the outset of South Korean President Lee Myung-bak's five-year term. He demanded progress on the disarmament talks before resuming aid.
Russia, one of the six parties to the disarmament talks, expects them to resume soon, its foreign ministry spokesman said on Wednesday.
Experts have noted that North Korea could better survive natural disasters if it adopted more market-based food policies.
North Korea's Public Distribution System was the main source of food for most North Koreans until it broke down during the mid-1990s famine. Gradually, the regime allowed a limited form of commercial trading to develop. The majority of people began to rely on crude rural markets to survive.
But in 2005, the state clamped down on the market system, reverting to the PDS, which can ensure food goes to soldiers, officials, party apparatchiks and priority workers but has again proved unable to meet most people's needs, North Korean experts said.
That became evident again this year.
North Korea's standard daily food ration is 700 grams of cereals per person per day. After the harsh winter it was reduced to 400 grams, then cut further to 150 grams in June, officials said. From July it was raised back to 200 grams, where it remains -- about a third of the government's minimum standard of 573 grams.
Back in March, the World Food Programme predicted the PDS would run out of food by early summer. In fact, it didn't -- possibly because of the drastic reductions in rations. One of the tasks of the U.N. assessment mission this month is to figure out why.
AlertNet was not permitted to visit the struggling rural markets where farmers are allowed to barter goods, although a few people were seen on the roadside selling potatoes, eggs, fruit and cigarettes.
The October rice crop will soon be harvested here, and official expectations are muted.
"We're only expecting about 45 percent of the rice crop to come through," said the senior official from the South Hwanghae People's Committee.
However, a North Korean Red Cross official said he was optimistic about the rice harvest, as there had been plenty of sunshine since mid-August.
All over the province, AlertNet saw lush-looking paddies with golden-green rows swaying in the breeze. Under a balmy autumn sun, some men, women and children were beginning to reap rice, working the rows with hand-held sickles.
Visitors to the central parts of the country, including areas around Pyongyang, have also reported seeing crops in good condition.
Red flags marked paddies ready for early harvest and enormous signs proclaimed: "Let's all help the farmers!"
Some farmers used ox-drawn carts to transport produce. Not a single piece of farm machinery was seen during the trip.
Many houses were surrounded by small kitchen gardens, with climbing beans and even melons growing onto roofs. Personal plots were crammed with cabbages, radishes and other vegetables.
A woman whose house was destroyed by floods at the Soa-Ri collective farm showed the food stocks she kept in her tarpaulin tent: corn and a few green leaves.
"I had about 15 square meters by my house that I was allowed to cultivate for myself, but everything was washed away," she said. "So now I have to dig wild grass."
Jeremy Laurence contributed to this report.