Mortality gaps persist for North Korean refugees in South Korea, study finds

North Korean refugees who resettled in South Korea faced persistently higher death rates than matched South Korean men over two decades of follow-up, while women showed an early survival advantage that faded with longer residence, according to a nationwide matched cohort study published in the International Journal for Equity in Health. The study used Korean National Health Insurance Service data linked to national death records from 2002 to 2022, following participants for up to 20 years after resettlement.

The researchers included 26,123 North Korean refugees aged 20 years or older after resettlement and matched them to 1,300,144 South Korean residents in a 1:50 ratio by sex, birth year, and calendar year of cohort entry. Over 11.3 million person-years of follow-up, with a median of 10.0 years, mortality patterns differed by sex and by time since resettlement. Analyses used Cox proportional hazards models adjusted for comorbidities and medication use, with sex-stratified and time-varying analyses.

Male refugees had higher all-cause mortality than matched South Korean men throughout follow-up, with an adjusted hazard ratio of 1.68 (95% confidence interval, 1.52–1.86). This excess mortality among men was driven by deaths from infection, trauma or injury, cancer, and cardiovascular disease.

The picture for women was different. Among female North Korean refugees, all-cause mortality was lower than that of matched South Korean women during the first six years after resettlement, with an adjusted hazard ratio of 0.81 (95% confidence interval, 0.67–0.98). However, this early advantage attenuated with longer residence, meaning the initial gap between refugee women and their matched South Korean counterparts narrowed over time.

A central design feature of the study makes its findings notable: both refugees and comparison residents were enrolled in the same national health insurance system. Because the two groups shared an ancestral and linguistic background and entered the same health system after migration, the comparison offers a way to examine long-term mortality inequities associated with resettlement itself rather than differences in insurance coverage. Despite this shared coverage, mortality differences persisted, which the authors interpret as evidence that formal health insurance alone may not fully address the long-term health effects of pre-migration deprivation, displacement, and post-resettlement social conditions.

The study’s conclusions support long-term, sex-specific monitoring of refugee health beyond the initial reception period. The authors emphasize that forced migration exposes populations to major changes in social, environmental, and health-system conditions, and that long-term mortality after resettlement has remained poorly characterized.

Subject of Research: Long-term sex-specific mortality among North Korean refugees resettled in South Korea compared with matched residents

Article Title: Sex-specific long-term mortality inequities among North Korean refugees resettled in South Korea: a nationwide matched cohort study

Article References: Kim, K. J., Choi, J., Kim, J. A., Kim, K. J., Lee, Y. H., Robinson, C., & Kim, S. G. (2026). Sex-specific long-term mortality inequities among North Korean refugees resettled in South Korea: a nationwide matched cohort study. International Journal for Equity in Health. https://doi.org/10.1186/s12939-026-03077-6

Image Credits: AI Generated

DOI: 10.1186/s12939-026-03077-6

Keywords: North Korean refugees, South Korea, mortality, cohort study, health inequities, resettlement, National Health Insurance, sex differences, infection, trauma, Sex-specific, long-term