Most studies that look at whether democracy improves global health rely on measurements of life expectancy at birth and infant mortality rates. Yet those measures disproportionately reflect progress on infectious diseases — such as malaria, diarrheal illnesses and pneumonia — which relies heavily on foreign aid.

A new study led by Stanford Health Policy's Tara Templin and the Council on Foreign Relations suggests that a better way to measure the role of democracy in public health is to examine the causes of adult mortality, such as noncommunicable diseases, HIV, cardiovascular disease and transportation injuries. Little international assistance targets these noncommunicable diseases. 

When the researchers measured improvements in those particular areas of public health, the results proved dramatic.

“The results of this study suggest that elections and the health of the people are increasingly inseparable,” the authors wrote.

A paper describing the findings was published today in The Lancet. Templin, a graduate student in the Department of Health Research and Policy, shares lead authorship with Thomas Bollyky, JD, director of the Global Health Program at the Council on Foreign Relations.

“Democratic institutions and processes, and particularly free and fair elections, can be an important catalyst for improving population health, with the largest health gains possible for cardiovascular and other noncommunicable diseases,” the authors wrote.

Templin said the study brings new data to the question of how governance and health inform global health policy debates, particularly as global health funding stagnates.

“As more cases of cardiovascular diseases, diabetes and cancers occur in low- and middle-income countries, there will be a need for greater health-care infrastructure and resources to provide chronic care that weren’t as critical in providing childhood vaccines or acute care,” Templin said.

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Free and fair elections for better health

In 2016, the four mortality causes most ameliorated by democracy — cardiovascular disease, tuberculosis, transportation injuries and other noncommunicable diseases — were responsible for 25 percent of total death and disability in people younger than 70 in low- and middle-income countries. That same year, cardiovascular diseases accounted for 14 million deaths in those countries, 42 percent of which occurred in individuals younger than 70.

Over the past 20 years, the increase in democratic experience reduced mortality in these countries from cardiovascular disease, other noncommunicable diseases and tuberculosis between 8-10 percent, the authors wrote.

“Free and fair elections appear important for improving adult health and noncommunicable disease outcomes, most likely by increasing government accountability and responsiveness,” the study said.

The researchers used data from the Global Burden of Diseases, Injuries, and Risk Factors Study; V-Dem; and Financing Global Health databases. The data cover 170 countries from 1970 to 2015.

What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health-care investments.

HIV-free life expectancy at age 15, for example, improved significantly — on average by 3 percent every 10 years during the study period — after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.

Watch: Some of the authors of the study discuss the significant their findings: 

What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health-care investments.

HIV-free life expectancy at age 15, for example, improved significantly — on average by 3 percent every 10 years during the study period — after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.

Foreign aid often misdirected

And yet, this connection between fair elections and global health is little understood.

“Democratic government has not been a driving force in global health,” the researchers wrote.  “Many of the countries that have had the greatest improvements in life expectancy and child mortality over the past 15 years are electoral autocracies that achieved their health successes with the heavy contribution of foreign aid.”

They note that Ethiopia, Myanmar, Rwanda and Uganda all extended their life expectancy by 10 years or more between 1996 and 2016. The governments of these countries were elected, however, in multiparty elections designed so the opposition could only lose, making them among the least democratic nations in the world.

Yet these nations were among the top two-dozen recipients of foreign assistance for health.

Only 2 percent of the total development assistance for health in 2016 was devoted to noncommunicable diseases, which was the cause of 58 percent of the death and disability in low-income and middle-income countries that same year, the researchers found.

“Although many bilateral aid agencies emphasize the importance of democratic governance in their policy statements,” the authors wrote, “most studies of development assistance have found no correlation between foreign aid and democratic governance and, in some instance, a negative correlation.”

Autocracies such as Cuba and China, known for providing good health care at low cost, have not always been as successful when their populations’ health needs shifted to treating and preventing noncommunicable diseases. A 2017 assessment, for example, found that true life expectancy in China was lower than its expected life expectancy at birth from 1980 to 2000 and has only improved over the past decade with increased government health spending. In Cuba, the degree to which its observed life expectancy has exceeded expectations has decreased, from four-to-seven years higher than expected in 1970 to three-to-five years higher than expected in 2016.

“There is good reason to believe that the role that democracy plays in child health and infectious diseases may not be generalizable to the diseases that disproportionately affect adults,” Bollyky said. Cardiovascular diseases, cancers and other noncommunicable diseases, according to Bollyky, are largely chronic, costlier to treat than most infectious diseases, and require more health care infrastructure and skilled medical personnel.  

The researchers hypothesize that democracy improves population health because:

1. When enforced through regular, free and fair elections, democracies should have a greater incentive than autocracies to provide health-promoting resources and services to a larger proportion of the population;
2. Democracies are more open to feedback from a broader range of interest groups, more protective of media freedom and might be more willing to use that feedback to improve their public health programs;
3. Autocracies reduce political competition and access to information, which might deter constituent feedback and responsive governance.

Various studies have concluded that democratic rule is better for population health, but almost all of them have focused on infant and child mortality or life expectancy at birth.

Over the past 20 years, the average country’s increase in democracy reduced mortality from cardiovascular disease by roughly 10 percent, the authors wrote. They estimate that more than 16 million cardiovascular deaths may have been averted due to an increase in democracy globally from 1995 to 2015. They also found improvements in other health burdens in the countries where democracy has taken hold: an 8.9 percent reduction in deaths from tuberculosis, a 9.5 percent drop in deaths from transportation injuries and a 9.1 percent mortality reduction in other noncommunicable disease, such as congenital heart disease and congenital birth defects.

“This study suggests that democratic governance and its promotion, along with other government accountability measures, might further enhance efforts to improve population health,” the study said. “Pretending otherwise is akin to believing that the solution to a nation’s crumbling roads and infrastructure is just a technical schematic and cheaper materials.”

The other researchers who contributed to the study are Matthew Cohen, Diana Schoder, Joseph Dieleman and Simon Wigley, from CFR, the University of Washington-Seattle and Bilkent University in Turkey, respectively.

Funding for the research came from Bloomberg Philanthropies and the Bill & Melinda Gates Foundation. Stanford’s Department of Health Research and Policy also supported the work.

 

 

On February 21–22, faculty and fellows from Stanford University traveled to Oahu, Hawaii for an orientation visit at the United States Indo-Pacific Command (INDOPACOM), the U.S. military command responsible for the conduct of the U.S. military’s missions throughout the Indian and Pacific Oceans, and Asia.

The visit brought together scholars and researchers from Stanford, the Massachusetts Institute of Technology, the Council on Foreign Relations, and Macquarie University, Australia. Organized by the U.S.-Asia Security Initiative (USASI) and the Shorenstein Asia-Pacific Research Center at the Freeman Spogli Institute for International Studies (FSI), the visit included meetings with the commanders and staffs of INDOPACOM and five of its subordinate commands (U.S. Army Pacific, U.S. Pacific Fleet, U.S. Air Forces Pacific, U.S. Marine Forces Pacific, and U.S. Special Operations Command Pacific), and a tour of Arleigh Burke-class Aegis destroyer USS John Paul Jones (DDG-52).

The visitors also interacted with the U.S. Army’s 25th Infantry Division’s leadership and the unit’s Jungle Training Center. The busy itinerary provided the group a superb opportunity to learn about INDOPACOM’s and its subordinate units’ threat assessments, capabilities, doctrine, regional partnerships, and readiness challenges.

These trips offer great access to America’s armed forces to those whose research focuses on or relates to national security issues, says Karl Eikenberry.

Karl Eikenberry, Director of the U.S.-Asia Security Initiative (USASI), a former U.S. ambassador to Afghanistan and himself a retired U.S. Army lieutenant general said: “USASI has over the past five years organized annual trips to U.S. military commands for Stanford FSI faculty and fellows. These trips offer great access to America’s armed forces to those whose research focuses on or relates to national security issues. The insights gained inform analysis, while the host organizations gain fresh perspectives different from those found within their commands.”

 

Discussions began on February 21st at Camp H.M. Smith, the Headquarters of INDOPACOM. Brigadier General Jonathan Braga, U.S. Army, SOCPAC Commander and his staff discussed his command’s unique capabilities and roles in both conventional and counterterrorist/counterinsurgency warfare operations. Major General Michael Minihan, U.S. Air Force, INDOPACOM Chief of Staff, then hosted a wide-ranging session on his organization’s implementation of the National Security Strategy and National Defense Strategy at a time of dynamic change within the region.

 

This was followed by a working lunch at the INDOPACOM Flag Mess with key staff members of MARFORPAC who explained U.S. Marine force posture and contingency missions throughout the Pacific Region. The Stanford group then proceeded to Hickam Field and met with General Charles Brown, Commander, PACAF, and his Deputy Commander, Major General Russell Mack. General Brown detailed the critical role played by airlift and airpower in the vast Indo-Pacific region, and the development of new concepts for the employment of U.S. Air Force capabilities in joint (inter-service) and combined (inter-allied) operations.

 

The visiting faculty and fellows then transited to Pearl Harbor for a tour of USS John Paul Jones led by Commanding Officer, Commander Jesse Mink, United States Navy, and Executive Officer, Commander Robert Watts, USN. Noteworthy was the destroyer’s sophisticated integrated air, surface, and underseas warfare systems, and the emphasis placed on resilience in high-end combat situations. Following the ship tour, the group attended a PACFLT command briefing chaired by the Commander, Admiral John Aquilino.

The dialogue made clear PACFLT’s emphasis on a holistic approach to deterrence and decisive operations, with an eye on future requirements. The first day of the trip ended with a working reception at the historic “Nimitz House” hosted by Admiral Aquilino, offering the attendees a chance to engage in conversations with the Commander and his staff.

The second day of the trip began with an introduction to the Daniel K. Inouye Asia-Pacific Center for Security Studies (APCSS), followed by expert presentations and breakout sessions on select topics including the Chinese One Belt One Road plan, the security of Taiwan, pandemic threats in the Indo-Pacific region, and cyber operations. The Stanford team then traveled to Fort Shafter for a meeting with Brigadier General Pete Andrysiak, U.S. Army and Chief of Staff, USARPAC. BG Andrysiak and the USARPAC staff elaborated on the evolving U.S. Army’s regional doctrine and extensive partnership activities.

A highlight of the group’s time in Oahu came with a visit to the U.S. Army’s 25th Infantry Division at Schofield Barracks, and the 25th ID Jungle Training center via UH-60 Blackhawk Helicopters. There Brigadier General J.B. Vowell, Assistant Division Commander, 25th Infantry Division and U.S. Army Hawaii (himself a former FSI Senior Military Fellow), discussed the division’s extensive missions throughout the region, including in the Korean Peninsula.

 

Faculty and fellows were also able to “get their boots (or at least tennis shoes) muddy” in the U.S. Army’s rugged training area in northern Oahu, with highly skilled soldiers demonstrating jungle warfare tactics and techniques. The trip ended with the participants hosting a reception at the Hale Koa Hotel Warriors Lounge for their many hosts over the past two days.

The trip to INDOPACOM Headquarters provided a rare opportunity for participants to talk directly with senior U.S. military leaders in the most important region of the world and to gain a better understanding of their perspectives and the many challenges that they are addressing. Faculty and fellows interacted with junior leaders at the tactical level, helping them gain an appreciation of the ethos of those serving at the cutting edge. The hosts all commented on the benefit of learning the views of scholars, many of whom have spent their academic careers writing about national security issues.

The trip provided fascinating insights into how the U.S. military views the rapidly evolving national security challenges in the Indo-Pacific region, says Larry Diamond.

“The trip provided fascinating insights into how the U.S. military views the rapidly evolving national security challenges in the Indo-Pacific region, and how it is organized to defend against the threats. You can read about much of this in the media and the journals, but there is just no substitute for being there, seeing our facilities on the ground, and engaging directly with the remarkable men and women (and one thing that struck me is that there are quite a number of women) who are responsible for our defense,” said Larry Diamond, senior fellow at the Hoover Institution and at the Center on Democracy, Development & the Rule of Law (CDDRL) at FSI.

FSI scholars particularly valued the opportunity to connect one-on-one.

“It was invaluable to meet and hear directly from the individuals and organizations who are working so hard to ensure our security,” said Center for International Security and Cooperation (CISAC) Senior Research Scholar Megan Palmer. For CISAC Pre-doctoral Fellow Erik Lin-Greenberg, “the opportunity to interact with decision-makers from tactical to strategic levels was incredibly valuable and helped inform my own research.”

This post was originally published on Axios.

Where it stands: Trump and Kim each face immense pressure, both international and domestic, to make progress.

• Trump needs to earn political trust back in Washington to continue negotiating with North Korea. His strategy so far has been to convince Kim that North Korea’s denuclearization would bring the country a “bright future.”
• At the same time, Trump must address Kim’s concerns about whether any agreement reached with his administration will withstand the Democrat-controlled House and survive the post-Trump era.

Between the lines: Successful diplomacy sometimes entails purposeful ambiguities, and the ambiguities of the first Trump-Kim summit might indeed have been strategic. At this critical juncture, however, a failure on Trump’s and Kim’s part to commit to defined objectives could hurt the bilateral relationship.

The bottom line: Trump and Kim need support more than ever to advance their diplomatic endeavors. While spectators have good reason to be skeptical, and one can only be cautiously hopeful with North Korea, a return to confrontation or "strategic patience" is in no one’s interest.

Gi-Wook Shin is the William J. Perry Professor of Contemporary Korea and director of the Walter H. Shorenstein Asia-Pacific Research Center at Stanford University.

Shorenstein APARC is pleased to announce the selection of two scholars as postdoctoral fellows for the 2019-20 academic year. They will begin their appointments at Stanford in the coming Autumn quarter.

The Center offers the Shorenstein Postdoctoral Fellowship on Contemporary Asia to recent doctoral graduates dedicated to research and writing on contemporary Asia, primarily in the areas of political, economic, or social change in the Asia-Pacific region, or international relations and international political economy in the region. The Center’s Asia Health Policy Program sponsors the Asia Health Policy Postdoctoral Fellowship, supporting young scholars who pursue original research on contemporary health or healthcare policy of high relevance to low- and middle-income countries in the Asia-Pacific region

Fellows develop their dissertations and other projects for publication, present their research, and participate in the intellectual life at the Center and at Stanford at large. Our postdoctoral fellows often go on to pursue careers at top universities and research organizations around the world and continue to contribute to APARC research and publications.

Meet our new postdoctoral scholars:

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What are the conditions necessary to ensure the effectiveness of public health insurance programs?

Radhika Jain is completing her doctorate in the Department of Global Health at Harvard University. She studies the role of the private sector in the health system, frictions in health care markets, and the incidence of public health policy benefits.

Radhika’s dissertation examines the extent to which government subsidies for health care under insurance are captured by private hospitals instead of being passed through to patients, and whether accountability measures can help patients claim their entitlements. Radhika’s research has been supported by grants from the Weiss Family Fund and the Jameel Poverty Action Lab (JPAL). She has worked on impact evaluations of health programs in India and on the implementation of HIV programs across several countries in sub-Saharan Africa. She also held a doctoral fellowship at the Center for Global Development.

At Shorenstein APARC, Radhika will refine her dissertation research for publication in academic journals and start new work on the structure of health care markets in India and the impacts of measures to increase the effectiveness of public health insurance.  

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How does modernization influence cultural democratization in East Asia?

Hannah June Kim is completing her doctorate in the Department of Political Science at the University of California, Irvine. She researches public opinion, political behavior, theories of modernization, economic development, and democratic citizenship, focusing on East Asia.

Hannah’s dissertation examines how and why people view democracy in systematically different ways in six countries: China, Japan, Korea, Singapore, Taiwan, and Vietnam. Developing unique categories of democratic citizenship that measure the cognitive, affective, and behavioral patterns of individuals, she finds that state-led economic development limited the growth of cultural democratization among middle class groups in all three dimensions. The results imply that the classic causality between modernization and democratization may not be universally applicable to different cultural contexts.

At Shorenstein APARC, Hannah will work on developing her dissertation into a book manuscript and make progress on her next project that explores democratization and gender empowerment in East Asia. Hannah received an MA in International Studies from Korea University and a BA from UCLA. Her work has been published, or is forthcoming, in The Journal of Politics, PS: Political Science & Politics, and the Japanese Journal of Political Science.