North Korea has faced enormous challenges in providing health and food security for its population since its economic collapse and famine of the 1990s. A principal reason was prioritizing state security in the military-first policy under Kim Jong Il and later advancing nuclear and missile programs under Kim Jong Un. Self-reliance ideology was another important factor. In addition, the unresolved Korean War and underlying North Korean perceptions of U.S. and international hostility cast a cold shadow over diplomatic and economic cooperation.