North Korea’s first-reported Covid-19 outbreak is the “greatest turmoil” to befall the country since its founding more than 70 years ago, according to its leader Kim Jong Un, as the isolated and impoverished nation scrambles to curb the spread of a highly transmissible virus that risks causing a major humanitarian crisis. North Korea reported 15 more deaths and 296,180 new “fever cases” between Friday and Saturday evening, according to state media KCNA, though it did not specify how many of the deaths and cases were linked to Covid, likely due to the country’s extremely limited testing capacity. That brought the total death toll to 42, according to KCNA, and the total number of fever cases to 820,620, with 496,030 fully recovered and 324,550 receiving medical care. The climbing death toll and surging “fever cases” come after North Korea said Thursday it had identified its first ever case of Covid-19 – an alarming development for a country with one of the world’s most fragile public health systems and a largely unvaccinated population. But given the opaque nature of the regime and the country’s isolation from the world – a trend that has only exacerbated since the pandemic – it is extremely difficult to assess the real situation on the ground. Foreign diplomats and aid workers had fled North Korea en masse in 2021 due to shortages of goods and “unprecedented” restrictions on daily life, making it all the more impossible to obtain information from the country other than through official state media. But North Korean state media reports have been vague, and many important questions remain unanswered, including the country’s vaccine coverage and the lockdown’s impact on the livelihood of its 25 million people. Here is what we know, and what we don’t know about the outbreak: How did the outbreak emerge? North Korean authorities have not announced the cause of the outbreak. North Korea’s borders have been tightly sealed since January 2020 to keep the virus at bay, making the so-called “hermit nation” even more isolated from the world. It even declined invitations to send teams to compete at the Tokyo and Beijing Olympics, citing the threat of Covid-19. And as new variants began to emerge, it stepped-up those efforts, cutting off nearly all trade with China – the country’s biggest trading partner and economic lifeline for the Kim regime – with imports from Beijing dropping 99% from September to October 2020. It remains unclear how the virus slipped through the country’s tightly-sealed borders. When KCNA reported on the first identification of Covid-19 in the country on Thursday, it did not even specify how many infections had been defected. It simply said samples collected from a group of people experiencing fevers on May 8 had tested positive for the highly contagious Omicron variant. By Friday, KCNA was reporting that 18,000 new “fever cases” and six deaths were recorded on Thursday, including one who tested positive for the BA.2 sub-variant of Omicron. “A fever whose cause couldn’t be identified explosively spread nationwide since late April,” the newspaper said. “As of now up to 187,800 people are being isolated.” On Saturday, KCNA said a total of 524,440 people had reported “fever” symptoms between late April and May 13. Among them, 280,810 people were still being treated in quarantine, while the rest had recovered. Can North Korea cope with a large-scale outbreak? An outbreak of Covid-19 could prove disastrous for North Korea. The country’s dilapidated health care infrastructure and lack of testing equipment is unlikely to be up to the task of treating a large number of patients with a highly infectious disease. North Korea’s lack of transparency and unwillingness to share information also poses a challenge. North Korea has never formally acknowledged how many died during a devastating famine in the 1990s that experts suggest killed as many as 2 million. Those who fled the country at the time shared horrific stories of death and survival, and a country in chaos. “North Korea has such a limited supply of basic medicine that public health officials need to focus on preventative medicine. They would be ill-equipped to deal with any kind of epidemic,” Jean Lee, director off the Hyundai Motor-Korea Foundation Center for Korean History at the Washington-based Woodrow Wilson Center, told CNN at the outset of the pandemic. Doctors who have defected in recent years often speak of poor working conditions and shortages of everything from medicine to basic healthcare supplies. Choi Jung-hun, a former physician in North Korea who fled the country in 2011, said when he was helping to combat a measles outbreak in 2006 to 2007, North Korea did not have the resources to operate round-the-clock quarantine and isolation facilities. He recalled that after identifying suspicious cases, manuals for doctors said patients were supposed to be transferred to a hospital or a quarantine facility for monitoring. “The problem in North Korea is that manuals are not followed. When there wasn’t enough food provided for the people at hospitals and quarantine facilities, people escaped to look for food,” Choi said during an interview with CNN in 2020. How is North Korea responding so far? North Korean state media declared the situation a “major national emergency” upon admitting the first officially reported Covid infection. On Thursday, Kim placed all cities into lockdown and ordered “people with fever or abnormal symptoms” into quarantine; he also directed the distribution of medical supplies the government had reportedly stocked in case of a Covid emergency, according to KCNA. Kim later chaired a meeting of the country’s powerful politburo, which agreed to implement “maximum” emergency anti-epidemic measures. The measures include isolating work units and pro-actively conducting medical checkups to find and isolate people with “fever and abnormal symptoms,” the KCNA reported Friday. “Practical measures are being taken to keep the production going at a high rate in the major sectors of the national economy and to stabilize the life of the people to the maximum,” KCNA said. According to KCNA, the politburo criticized the country’s anti-epidemic sector for “carelessness, laxity, irresponsibility and incompetence,” saying it “failed to respond sensitively” to increasing Covid-19 cases across the world, including in neighboring regions. A reporter for Chinese state media CGTN released a rare video from Pyongyang on Friday, recounting his experience on the ground. “As far as we know, not many people in Pyongyang have been vaccinated, and the medical and epidemic prevention facilities are in short supply,” reporter Zang Qing said in a Weibo post. “Because the capital is in lockdown, the food I have at home is only enough for a week. We are still awaiting what policy the government will announce next.” At a meeting Saturday, Kim inspected the country’s emergency epidemic measures and medical supplies. He also urged North Korean officials to learn from China’s “advanced and rich quarantine results and experience they have already achieved in their fight against the malicious infectious disease,” according to KCNA. What about North Korea’s vaccine coverage? North Korea is not known to have imported any coronavirus vaccines – despite being eligible for the global Covid-19 vaccine sharing program, Covax. Assuming most North Koreans are unvaccinated, an outbreak in the country – which has limited testing capabilities, inadequate medical infrastructure and which has isolated itself from the outside world – could quickly become deadly. Calls are mounting on the country’s leadership to provide access to vaccines. “There is no evidence to show that North Korea has access to enough vaccines to protect its population from Covid-19. Yet, it has rejected millions of doses of AstraZeneca and Sinovac vaccines offered by the WHO-led Covax program,” said Amnesty International’s East Asia researcher Boram Jang, in a statement. “With the first official news of a Covid-19 outbreak in the country, continuing on this path could cost many lives and would be an unconscionable dereliction of upholding the right to health.” In February, Covax reportedly scaled back the number of doses allocated to North Korea because the country failed to arrange for any shipments, according to Reuters. A spokesperson for Gavi, the Vaccine Alliance, said Covax has moved to “needs-based vaccine allocations” and “has currently not committed any volume” for North Korea. “In case the country decides to start a Covid-19 immunization program, vaccines could be made available based on criteria of Covax objectives and technical considerations to enable the country to catch up with international immunization targets,” the spokesperson said.