While academic political science has not had much to tell policymakers of late, there is one book that stands out as being singularly relevant to the events currently unfolding in Tunisia, Egypt and other Middle Eastern countries: Samuel Huntington’s Political Order in Changing Societies, first published over forty years ago.¹ Huntington was one of the last social scientists to try to understand the linkages between political, economic and social change in a comprehensive way, and the weakness of subsequent efforts to maintain this kind of large perspective is one reason we have such difficulties, intellectually and in policy terms, in keeping up with our contemporary world.

Huntington, observing the high levels of political instability plaguing countries in the developing world during the 1950s and 1960s, noted that increasing levels of economic and social development often led to coups, revolutions and military takeovers rather than a smooth transition to modern liberal democracy. The reason, he pointed out, was the gap that appeared between the hopes and expectations of newly mobilized, educated and economically empowered people on the one hand, and the existing political system, which did not offer them an institutionalized mechanism for political participation, on the other. He might have added that such poorly institutionalized regimes are also often subject to crony capitalism, which fails to provide jobs and incomes to the newly educated middle class. Attacks against the existing political order, he noted, are seldom driven by the poorest of the poor; they instead tend to be led by rising middle classes who are frustrated by the lack of political and economic opportunity—a phenomenon noted by Alexis de Tocqueville in his masterful analysis of the origins of the French Revolution and raised again in the early 1960s by James Davies’s well known “J-curve” theory of revolution.²

Something like this Huntingtonian process has unfolded in recent months in both Tunisia and Egypt. In both cases, anti-government protests were led not by the urban poor or by an Islamist underground, but by relatively well-educated middle-class young people used to communicating with each other via Facebook and Twitter. It is no accident that Wael Ghonim, Google’s regional head of marketing, emerged as a symbol and leader of the new Egypt. The protesters’ grievances centered around the fact that the authoritarian regimes of Ben Ali and Mubarak offered them no meaningful pathway to political participation, as well as failing to provide jobs befitting their social status. The protests were then joined by other groups in both societies—trade unionists, Islamists, peasants and virtually everyone else unhappy with the old regimes—but the driving force remained the more modern segments of Tunisian and Egyptian society.

Societies lacking institutions that could accommodate new social actors produced a condition Huntington labeled praetorianism, in which political participation took the form of strikes, demonstrations, protests and violence. The military often seized power in such circumstances because it was the only organized actor in society capable of running a government. The Egyptian Republic’s first autocrat, Gamal Abdel Nasser, came to power in precisely this manner back in July 1952, when his Free Officers movement represented the rising Egyptian middle class. The tragedy of modern Egypt is that there has been scarcely any meaningful political development in the more than half-century since then—meaning, in Huntington’s terms, the rise of modern institutions that could peacefully channel citizen participation.

Socioeconomic development, meanwhile, has proceeded apace: Between 1990–2010 Tunisia’s Human Development Index (a composite measure of health, education and income compiled by the UN) rose 30 percent, while Egypt’s rose 28 percent. Both countries produced tens of thousands of college graduates with no discernable future and a lopsided income distribution in which a disproportionate share of the gains from growth went to a small group of politically connected insiders. Huntington’s analysis of Egypt in the 1950s and 1960s thus remains eerily relevant today.

In Political Order Huntington was also making a broader point about the process of development itself. The significance of his book needs to be seen against the backdrop of post-World War II modernization theory, which in turn drew on classic 19th-century European social theory articulated by academics like Edward Shils, Talcott Parsons and Walt W. Rostow. American modernization theory argued that development was a single, seamless process. Economic development, changing social relationships like the breakdown of extended kinship groups and the growth of individualism, higher and more inclusive levels of education, normative shifts toward values like “achievement” and rationality, secularization and the growth of democratic political institutions, were all seen as an interdependent whole.

By pointing out that the good things of modernity did not necessarily go together, Huntington played a key role in killing off modernization theory. Political development was a separate process from socioeconomic development, he argued, and needed to be understood in its own terms. The conclusion that flowed from this point of view seemed at the time counterintuitive to the point of stunning: Without political development, the other aspects of modernization could lead to bad results—to tyranny, civil war and mass violence.

There were other reasons why Western modernization theory fell into disrepute by the 1970s: It came to be regarded as too Eurocentric—indeed, as too Americentric insofar as it seemed to posit American society as the pinnacle of modernization. It failed to recognize the possibility that countries like Japan and China might take roads to modernity that would look very different from the ones pioneered by Britain and the United States. But even if one agreed that the end point of development should be some form of industrialized liberal democracy, Huntington made it clear that arriving at the desired destination was far more elusive and complicated than modernization theorists believed.

The central piece of policy advice that emerged out of Huntington’s work was the concept of the “authoritarian transition.” If political systems opened up to democratic contestation too early, before the development of political parties, labor unions, professional associations and other organizations that could structure participation, the result could be chaotic. Authoritarian regimes that could maintain order and promote economic growth, Huntington argued, might oversee a more gradual institutionalization of society, and make a transition to democracy only when broad participation could be peacefully accommodated. This form of sequencing, in which economic development was promoted before a democratic opening, was the path followed by Asian countries like South Korea and Taiwan, which made democratic transitions in the late 1980s only after they had succeeded in turning themselves into industrialized powerhouses. It was also the development strategy recommended by Huntington’s former student Fareed Zakaria, as well as by the leaders of many authoritarian governments, who liked the idea of economic growth better than the idea of democratic participation.³ We will return to the question of how well that strategy worked in the Middle East later.

Development in Silos 

As interesting and important as Huntington’s work was, it lay outside of mainstream thinking about development, which from the start was a highly Balkanized academic field that was dominated by economists. Few scholars have sought to understand development as an inter-connected process with political, economic and social parts. Few scholars have sought to understand development as an inter-connected process with political, economic and social parts.Development economists looked primarily at economic factors like capital, labor and technology as sources of economic growth, and thought neither about the consequences of growth for politics nor the relationship of political institutions to growth. The Harrod-Domar growth model that was dominant in the 1950s suggested that less-developed countries were poor primarily because they lacked capital, which then led development agencies like the World Bank to try to kick start growth with generous infusions of capital for physical infrastructure. It was only when steel plants and shoe factories in sub-Saharan Africa went idle due to corruption or lack of organizational capacity that they were forced to go back to the drawing board.

The political scientists, for their part, scaled back their ambitions from large Huntingtonian-style theory and focused primarily on political phenomena. Beginning in the 1980s, there was increasing interest in the problem of transitions into and out of democracy; with democratic transitions in Spain, Portugal and nearly all of Latin America, this became a particularly pressing issue. There was some revival of interest in the democracy-development linkage, but it never led to a clear consensus on the causal links connecting the two phenomena.

The academic interest in transitions corresponded to the burgeoning of democracy promotion as a distinct field of international practice, both on the part of the United States and of other democracies around the world. The idea was planted during the 1970s, when the institutes linked with the German political parties played a key role in beating back an attempted Communist takeover in Portugal and facilitating that country’s transition to democracy. The 1980s saw the establishment of the National Endowment for Democracy (NED), a taxpayer-funded but quasi-independent organization devoted to support of pro-democracy groups around the world. One of the NED’s early successes was its funding of the Solidarity trade union in Poland before the collapse of communism. The 1990s saw the growth of a host of international organizations capable of monitoring elections and the funding of the Democracy and Governance branch of the U.S. Agency for International Development to the tune of almost $1.5 billion annually.

By the late 1990s, there was some degree of convergence in the agendas of economists and political scientists. By that point Douglass North and the school of “New Institutional Economics” he founded made economists aware of the importance of political institutions—particularly property rights—for economic growth. Economists increasingly sought to fold political variables like legal systems and checks on executive power into their models. Political science had itself been colonized at this point by economic methodology, and it was natural for such rational-choice political scientists to start looking at the economic impact of political institutions.

The return to a more interdisciplinary approach to development was marked as well by the tenure of James Wolfenson as President of the World Bank from 1995 to 2005.⁴ Wolfenson early on gave a speech on the “cancer of corruption” and signaled to the institution that, henceforth, political issues like corruption and good governance would be taken seriously. The publication of the 1997 World Development Report, The State in a Changing World, marked an intellectual break with the Washington Consensus focus on economic policy and state downsizing, and the Bank created a new branch devoted to reform of developing country public sectors. These changes constituted an open admission that politics was a critical component of development, and that the state was not simply an obstacle to growth but often a necessary underpinning for it. Increasingly, donor agencies have seen the promotion of democratic accountability as one tool in the fight against corruption.

This modest degree of convergence should not, however, obscure the continuing degree of compartmentalization that exists in the field of development. While paying lip service to the importance of institutions, most economists and field practitioners still see politics as at best an obstacle to the real work of development, which is improvement in incomes, health, education and the like, and not as an independent objective of development strategy. (Amartya Sen is an important exception to this generalization.) The democracy promotion agencies, for their part, spend relatively little time worrying about economic growth, social policy or public health, which in their view are goods often used by authoritarian regimes to buy off populations and prevent democratization.

The intellectual confusion surrounding development has led to severely Balkanized policies both in the United States and in the international community that often work at cross purposes from one another.The intellectual confusion surrounding development has led to severely Balkanized policies both in the United States and in the international community that often work at cross purposes from one another. For example, the authoritarian or semi-authoritarian regimes of Meles Zenawi in Ethiopia, Paul Kagame in Rwanda and Yoweri Museveni in Uganda have been aid darlings over the past decade because of their track records in promoting economic, health and social goals. At the same time, democracy promotion groups have been highly critical of them and have supported opposition groups and civil society organizations seeking accountability and limits on executive power. To be sure, aid agencies don’t object to greater government accountability on the part of these regimes, while the democracy promotion community wouldn’t stand in the way of progress on HIV/AIDS or malaria. Yet no one takes a larger view and asks, for example, whether existing aid programs are helping to keep the regime in power or, conversely, are destabilizing it.

Egypt itself presents a good case of this particular form of policy incoherence. Despite the fact that Egypt ranks as one of the top American aid recipients, it is hard to say that Washington was pursuing development goals of any sort there. The United States was primarily interested in stability. Despite brave speeches on democracy by both Condeleezza Rice and Barack Obama in Cairo, the United States actually pulled its punches in pushing serious democratic reform on Egypt, particularly after the Hamas electoral victory in Gaza in 2006. Nonetheless, U.S. economic aid programs were still pushing education and economic policy reform programs in the country. Had American aid administrators taken the Huntingtonian view that their assistance was covertly designed to promote an expectations gap and delegitimate Hosni Mubarak, this might have been a clever strategy. But no such cleverness existed. Instead, it was simply an example of compartmentalized aid programs doing their thing in ignorance of the interdependent effects of politics and economics.

What Is to Be Done?

Ideas precede action. Before we can hope to generate a coherent set of policies for Egypt, or anywhere else for that matter, we need a better understanding of development—that is, how changes in economy, politics and society over time constitute a set of discrete yet interlinked processes. Whatever the shortcomings of classic modernization theory, it at least began from the insight that the phenomenon under study required development of a master social science that transcended existing disciplinary boundaries. This objective is as far away as ever in academia, where the traditional disciplines keep a chokehold on how younger academics think and do research. Today, the single most popular form of development dissertation in both economics and political science is a randomized micro-experiment in which the graduate student goes out into the field and studies, at a local level, the impact of some intervention like the introduction of co-payments for malaria mosquito netting or changes in electoral rules on ethnic voting. These studies can be technically well designed, and they certainly have their place in evaluating projects at a micro level. But they do not aggregate upwards into anything that can tell us when a regime crosses the line into illegitimacy, or how economic growth is changing the class structure of a society. We are not, in other words, producing new Samuel Huntingtons, with the latter’s simultaneous breadth and depth of knowledge.

On a policy level, we need far more mutual understanding between those who promote socioeconomic development and those who work on democracy promotion and governance.On a policy level, we need far more mutual understanding between those who promote socioeconomic development and those who work on democracy promotion and governance. Traditional development agencies like USAID already think politically to the extent that their aid projects are designed to support U.S. foreign policy. But they, like their counterparts in multilateral organizations like the World Bank, are not trained to do political economy analysis; they do not seek an understanding of the political context within which aid is used and abused, and what is not sought is very rarely found. We call for the liberalization of ports in Haiti, for example, without trying to understand which particular politicians are benefiting from existing arrangements that keep them closed. For their part, democracy promoters focus on democratic transitions, providing help to opposition parties and civil society organizations in authoritarian countries. But once a transition occurs, as it did after the Orange and Rose revolutions in Ukraine and Georgia, they have relatively little to offer new democratic governments in terms of policy agendas, anti-corruption strategies or help in improving the delivery of services that citizens want.

Beyond these relatively minor adjustments, a more robust theory of social change might tell us that, in certain circumstances, the best way to destabilize an authoritarian society would be not the funding of civil society groups seeking short-term regime change, but rather the promotion of rapid economic growth and the expansion of educational access.⁵ Conversely, there are many societies we know will simply waste development assistance dollars because they are ruled by unaccountable authoritarian regimes. In such circumstances, it might be a more efficient use of aid resources to cut development aid entirely and to work only for political change. This is, in effect, what has happened to Zimbabwe under Robert Mugabe, but the country had to sink very far before anyone considered pulling the aid plug.

Huntington got a number of things wrong. The authoritarian transition was not a universally applicable formula for development. It worked reasonably well in East Asia, where there were a number of figures like Lee Kwan Yew, Park Chung-hee or the Chinese Communist Party leadership, who used their autocratic powers to promote rapid development and social change. Arab authoritarians were cut from a different cloth, content to preside over economically stagnant societies. The result was not a coherent development strategy but a wasted generation.

The aspiration of social science to replicate the predictability and formality of certain natural sciences is, in the end, a hopeless endeavor. Human societies, as Friedrich Hayek, Karl Popper and others understood, are far too complex to model at an aggregate level. Contemporary macroeconomics, despite dealing with social phenomena that are inherently quantified, is today in crisis due to its utter failure to anticipate the recent financial crisis.

The part of social change that is the hardest to understand in a positivistic way is the moral dimension—that is, the ideas that people carry around in their heads regarding legitimacy, justice, dignity and community. The current Arab uprising was triggered by the self-immolation of an overeducated 26-year-old Tunisian vegetable seller whose cart was repeatedly confiscated by the authorities. After Mohamed Bouazizi was slapped by a policewoman when he tried to complain, he reached the end of his tether. Bouazizi’s public suicide turned into a social movement because contemporary communications technologies facilitated the growth of a new social space where middle-class people could recognize and organize around their common interests. We will probably never understand, even in retrospect, why the dry tinder of outraged dignity suddenly ignited in this fashion in December 2010 as opposed to 2009, or ten years before that, and why the conflagration spread to some Arab countries but not to others. But we can certainly do a better job in putting together the few pieces we do understand, in a way that would be useful to policymakers coping with the reality of social change.

¹Huntington, Political Order in Changing Societies: With a New Forward by Francis Fukuyama (Yale University Press, 2006).

²Davies, “Towards a Theory of Revolution”, American Sociological Review, Vol. 27 (1962).

³Zakaria, The Future of Freedom: Illiberal Democracy at Home and Abroad (W. W. Norton, 2003); see also Zakaria, “A Conversation with Lee Kuan Yew”, Foreign Affairs (March/April 1994).

⁴For a description of the Wolfenson presidency, see Sebastian Mallaby, The World’s Banker: A Story of Failed States, Financial Crises, and the Wealth and Poverty of Nations (Penguin Press, 2004).

⁵See Harold James’s retroview, entitled “Growing Pains”, of a classic December 1963 essay by Mancur Olson (“Rapid Growth as a Destabilizing Force”) in The American Interest (September/October 2006).

Can social, economic, and policy changes turn a period of growing old-age dependency into one of positive opportunity and growth in China? Qiong Zhang and Asia Health Policy Program director Karen Eggleston explore this challenging question in a recent China Brief article. They look back into several decades of China's history and also consider the current demographic picture of one-child families, gender imbalance, declining fertility rates, and a healthy and prosperous aging population.

In an opinion piece for Al Jazeera, Rajaie Batniji uncovers the role of medical professionals involved in acts of torture. With a lens to the unrest in Syria, Batniji calls for an international body to identify, monitor, and disqualify those complicit in torture and genocide.

Doctors have a long history of complicity in torture, but the torture of political dissidents holds a privileged place.  In Saddam Hussein's Iraq, surgeons removed the ears of men who failed to report for military service or defected from the army. In the Soviet Union, psychiatrists held political dissidents in mental hospitals with false diagnoses, in order to isolate and punish them. It is in this tradition of medical torture of dissidents that the Syrian healthcare establishment may be heading.

A July 6 report by Amnesty International documents the treatment of Wassim, a 21-year-old protester in the Syrian town of Talkalakh. After an injury from a soldier's bayonet, Wassim was taken to al-Bassel hospital, which had been occupied by Syrian security forces. As he reported: "The nurses, men and women […] swore at me and beat me hard and one female nurse punched me repeatedly with all her strength on my chest. Some were taking off their shoes and slapping me with them. I could hear many voices asking: 'You want freedom, eh?'" The report states he later had his wounds stitched without anesthesia, before being beaten on these wounds by hospital staff.  

Wassim's is not an isolated incident. In May, Reuters documented the case of a protester who had lost sensation in his legs who requested to see a doctor in jail. He told the news agency: "The doctor hit my knees with his legs, and asked: 'There, is it better now?' and then he slapped me". Most pervasively, reports suggest that even when doctors have not been involved in direct abuse, they have falsified the causes of injuries and released information about patients to the Syrian regime's security forces. The result is a public distrust of hospitals, and a clear incentive for injured protestors to avoid the healthcare system. 

The medical torture of political dissidents holds a privileged place because it can be perversely justified. The torture of dissidents may be seen as an act of loyalty to the state. Doctors acting on behalf of the state, such as military doctors, have what is called "dual loyalty" - loyalty to both their patient and a third party.

In addressing the issue of dual loyalty, Physicians for Human Rights has proposed guidelines that physicians not be present when torture takes place, and calls on them to report all human rights violations, especially when they interfere with their loyalty to patients. Like the medical professionals from the US recently implicated in the torture and abuse of prisoners at Guantánamo Bay and Iraq, some Syrian doctors may have valued their contribution to the security of the state more than their adherence to the norms of their profession. 

But, in their pursuit of perceived enemies of the state, have these physicians become enemies of the profession? Doctors involved in torture should be pursued as enemies of medicine: their crimes documented, their professional credentials revoked, and their ability to practice internationally thwarted.

Identifying and disqualifying doctors involved in torture

While it is exceedingly unlikely that Bashar al-Assad, an ophthalmologist, will go back to correcting cataracts in London - where he trained - if his regime is overthrown, other physicians culpable in his regime's torture will seek to continue clinical practice abroad.

Even with continued instability, it is likely that physicians and other elites will seek to emigrate. Could doctors involved in abuse head to Europe, North America or neighbouring Arab countries and continue to operate? How will they be identified? Critically, the majority of Syrian physicians that have not been complicit with abuses must be distinguished from those who have. 

Unfortunately, the medical profession has no method for identifying or punishing doctors complicit in torture. We rely on human rights organisations to provide sporadic documentation of medical torture.

With limited access and competing priorities - such as being able to provide medical care while working in countries where torture occurs - these organisations have a narrow scope for documenting the occurrence of torture. In an excellent Lancet article, Len Rubenstein and Melanie Bittle argue that the World Health Organization is best positioned to play a leading role in documenting attacks on medical functions in conflict, and this should include those attacks committed by physicians.

Among the suggestions put forth by Rubenstein and Bittle are a UN Security Council resolution providing a mandate for the WHO to pursue investigations, and the use of mobile devices for securely and quickly transmitting information about abuse. By documenting medical complicity in torture, we give physicians under incredible pressures incentive to oppose orders from their superiors and the state.

The greatest challenge, however, is enforcement, and the punishment of physicians complicit in torture. No international body retains information on professional qualifications. Like most other professions, medicine has proclaimed a need to be self-regulating, yet it has no system in place to disqualify or sanction physicians on a global level (national licensing bodies exist in most countries, but there is little to no international coordination). To this day, investigations continue of Rwandan doctors now practising in Europe and Africa, accused of involvement in the 1994 genocide.

Of course, their crimes were far more widespread than those in Syria today, as doctors oversaw the killing of hundreds of patients and staff in their hospitals, but the challenge of enforcement is nearly identical. Even if medical complicity in torture does not warrant imprisonment, it ought to warrant professional disqualification - and as of yet, no institution or process is in place to disqualify a physician from practising internationally. 

Honouring the heroism of Syrian doctors

Attacks on the healthcare system are common - perhaps inevitable - in modern war, but doctors don't always become complicit. In Bahrain, the Salmaniya medical centre was raided, and its doctors beaten and jailed for treating protesters. In Libya, Misurata hospital came under fire, deterring the sick from seeking care and endangering staff and patients.

Despicable as these attacks are, they have come to be expected as a feature of conflict. Attacks on the healthcare system have been documented in almost all recent conflicts including in Afghanistan, Kosovo, Nepal, Iraq, and the occupied Palestinian territories. In most cases, doctors have acted admirably, and sometimes heroically: seeing the sick in their homes, in secretive and makeshift clinics, risking their lives to provide care. Under oppressive regimes, doctors may be risking their lives just by refusing to be complicit in torture. 

In Syria, a group known as the "Damascus Doctors" has been organising on Facebook to provide hidden clinics in areas of protest, as reported by CNN. These doctors are upholding a tradition of professionalism and protest that existed since at least 1980, when more than 100 healthcare professionals were arrested for striking to demand the lifting of Syria's state of emergency, in place since 1963 (as of 1990, at least 90 of them remained missing). These doctors, like many others who have opposed the regime, were subjected to gruesome physical and psychological torture. 

The overwhelming majority of Syrian physicians have likely been acting heroically. It is in their honour that we should pursue aggressive international efforts to document and disqualify those physicians complicit in torture. This will require emboldened international institutions, cooperation among national licensing bodies, and the courage of doctors, journalists, activists and human rights organisations in documenting and reporting medical torture.