This article originally appeared at Brookings.

March 18 marks the fifth anniversary of Russia’s illegal annexation of Crimea, which capped the most blatant land grab in Europe since World War II. While the simmering conflict in Donbas now dominates the headlines, it is possible to see a path to resolution there. It is much more difficult with Crimea, which will remain a problem between Kyiv and Moscow, and between the West and Russia, for years—if not decades—to come.

THE TAKING OF CRIMEA

In late February 2014, just days after the end of the Maidan Revolution and Victor Yanukovych’s flight from Kyiv, “little green men”—a term coined by Ukrainians—began seizing key facilities on the Crimean peninsula. The little green men were clearly professional soldiers by their bearing, carried Russian weapons, and wore Russian combat fatigues, but they had no identifying insignia. Vladimir Putin originally denied they were Russian soldiers; that April, he confirmed they were.

By early March, the Russian military had control of Crimea. Crimean authorities then proposed a referendum, which was held on March 16. It proved an illegitimate sham. To begin with, the referendum was illegal under Ukrainian law. Moreover, it offered voters two choices: to join Russia, or to restore Crimea’s 1992 constitution, which would have entailed significantly greater autonomy from Kyiv. Those on the peninsula who favored Crimea remaining a part of Ukraine under the current constitutional arrangements found no box to check.

The referendum unsurprisingly produced a Soviet-style result: 97 percent allegedly voted to join Russia with a turnout of 83 percent. A true referendum, fairly conducted, might have shown a significant number of Crimean voters in favor of joining Russia. Some 60 percent were ethnic Russians, and many might have concluded their economic situation would be better as a part Russia.

It was not, however, a fair referendum. It was conducted in polling places under armed guard, with no credible international observers, and with Russian journalists reporting that they had been allowed to vote. Two months later, a member of Putin’s Human Rights Council let slip that turnout had been more like 30 percent, with only half voting to join Russia.

Regardless, Moscow wasted no time. Crimean and Russian officials signed a “treaty of accession” just two days later, on March 18. Spurred by a fiery Putin speech, ratification by Russia’s rubberstamp Federation Assembly and Federation Council was finished by March 21.

ATTEMPTS TO JUSTIFY

Moscow’s actions violated the agreement among the post-Soviet states in 1991 to accept the then-existing republic borders. Those actions also violated commitments to respect Ukraine’s sovereignty, territorial integrity, and independence that Russia made in the 1994 Budapest Memorandum on Security Assurances for Ukraine and 1997 Ukrainian-Russian Treaty of Friendship, Cooperation and Partnership.

In late March 2014, Russia had to use its veto to block a U.N. Security Council resolution that, among other things, expressed support for Ukraine’s territorial integrity (there were 13 yes votes and one abstention). The Russians could not, however, veto a resolution in the U.N. General Assembly. It passed 100-11, affirming Ukraine’s territorial integrity and terming the Crimean referendum invalid.

Russian officials sought to justify the referendum as an act of self-determination. It was not an easy argument for the Kremlin to make, given the history of the two bloody wars that Russia waged in the 1990s and early 2000s to prevent Chechnya from exercising a right of self-determination.

Russian officials also cited Western recognition of Kosovo as justification. But that did not provide a particularly good model. Serbia subjected hundreds of thousands of Kosovar Albanians to ethnic-cleansing in 1999; by contrast, no ethnic-cleansing occurred in Crimea. Kosovo negotiated with Serbia to reach an amicable separation for years before declaring independence unilaterally. There were no negotiations with Kyiv over Crimea’s fate, and it took less than a month from the appearance of the little green men to Crimea’s annexation.

The military seizure of Crimea provoked a storm of criticism. The United States and European Union applied visa and financial sanctions, as well as prohibited their ships and aircraft from traveling to Crimea without Ukrainian permission. Those sanctions were minor, however, compared to those applied on Russia after it launched a proxy conflict in Donbas in April 2014, and particularly after a Russian-provided surface-to-air missile downed a Malaysian Air airliner carrying some 300 passengers.

Whereas Ukrainian forces on Crimea did not resist the Russian invasion (in part at the urging of the West), Kyiv resisted the appearance of little green men in Donbas. Before long, the Ukrainians found themselves fighting Russian troops as well as “separatist” forces. That conflict is now about to enter its sixth year.

Finding a settlement in Donbas has taken higher priority over resolving the status of Crimea—understandable given that some 13,000 have died and two million been displaced in the fighting in eastern Ukraine. Moscow seems to see the simmering conflict as a useful means to pressure and distract Kyiv, both to make instituting domestic reform more difficult and to hinder the deepening of ties between Ukraine and Europe.

Resolving the Donbas conflict will not prove easy. For example, the Kremlin may not be prepared to settle until it has some idea of where Ukraine fits in the broader European order, that is, its relationship with the European Union and NATO. But Russia has expressed no interest in annexing Donbas. While the seizure of Crimea proved very popular with the broader Russia public, the quagmire in Donbas has not. The most biting Western economic sanctions would come off of Russia if it left Donbas. At some point, the Kremlin may calculate that the costs outweigh the benefits and consent to a settlement that would allow restoration of Ukrainian sovereignty there.

Moscow will not, on the other hand, willingly give up Crimea. Russians assert a historical claim to the peninsula; Catherine the Great annexed the peninsula in 1783 following a war between Russia and the Ottoman Empire. (That said, Crimea was transferred from the Russian Soviet Federative Socialist Republic to the Ukrainian Soviet Socialist Republic in 1954, and, as noted above, the republics that emerged from the wreckage of the Soviet Union in 1991 agreed to accept the borders as then drawn.)

Retaining Crimea is especially important to Putin, who can offer the Russian people no real prospect of anything other than a stagnant economy and thus plays the nationalism and Russia-as-a-great-power cards. He gained a significant boost in public popularity (much of which has now dissipated) from the rapid and relatively bloodless takeover of the peninsula. Moreover, it offers a vehicle for Russia to maintain a festering border dispute with Ukraine, which the Kremlin may see as discouraging NATO members from getting too close to Ukraine.

Kyiv at present lacks the political, economic, and military leverage to force a return. Perhaps the most plausible route would require that Ukraine get its economic act together, dramatically rein in corruption, draw in large amounts of foreign investment, and realize its full economic potential, and then let the people in Crimea—who have seen no dramatic economic boom after becoming part of Russia—conclude that their economic lot would be better off back as a part of Ukraine.

For the West, Russia’s seizure and annexation of Crimea pose a fundamental challenge to the European order and the norms established by the 1975 Helsinki Final Act. The United States and Europe should continue their policy of non-recognition of Crimea’s illegal incorporation. They should also maintain Crimea-related sanctions on Russia, if for no other reason than to signal that such land grabs have no place in 21st-century Europe.

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.