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.

Isabelle Foster was an undergraduate student at Stanford who applied for the Ford Dosey Master's in International Policy (MIP) co-terminal program in her junior year. The co-term allowed her to take classes towards her master's degree in her senior year. Isabelle, who is now technincally a second-year master's student, will graduate from MIP in June.

Curious as to what our current students have to say about the MIP program? Check out the first #MIPFeatureFriday featuring our graduate student, Isabelle Foster! Stay tuned every Friday for features on our MIP students and alumni. Read more about Isabelle's time with the MIP program. 

A new politics of constructive polarization may be needed to successfully overcome authoritarian politics, says Professor Somer in a recent interview with FSI Director Michael McFaul. 

Michael McFaul: You recently co-edited two special journal volumes on polarization, democracy, and democratic erosion in The Annals of the American Academy of Political and Social Science, and in The American Behavioral Scientist. What is political polarization and what are the causes of it?

Murat Somer: There are many definitions of polarization. For example, those based on the ideological distance between political parties. However, what concerns us about polarization with respect to its consequences for democracy is something else. To put it simply, polarization is the division of a society, of a people, into oppositional camps of “Us versus Them.” We begin to see each other in a zero-sum relationship and oppositional terms. What triggers it? Of course, in each specific country's context there may be different underlying reasons, or what may seem to be very different reasons. But what triggers it really is deeply political. It is a specific type of politics that we call in my joint work with Jennifer McCoy from Georgia State University “polarizing and transformative politics.” It taps into expectations for change in society and proclaims to pursue wide-scale transformations in existing institutions and social and economic structures. Polarizing politics is instrumental to this goal. Polarization is induced to unite and mobilize previously under-mobilized or divided constituencies and to weaken institutional and political resistance. It has many variations – such as populism and its left and right-wing subtypes – but we can group them into two main versions. One is more inclusive, in the sense of aiming to bring to power, or be more inclusive, of certain groups in society that were either objectively marginalized, excluded in the past, or who subjectively perceive themselves as such. Usually there's a discussion about that in each society, of course. It's rarely clear-cut for everybody.

McFaul: And we can distinguish between the two in a social scientific way? Or is that hard to do?

Somer: In terms of the political discourse of these movements, what they say they are trying to do, and then the makeup and the composition of these political parties or movements, we can identify the distinction. The second version is more exclusionary – it aims to represent groups that used to see themselves as the dominant group in society. But for one reason or another, which may for example result from demographic and institutional changes over time, who feel that they have been left behind, who feel threatened. Their dominant position or self-image is threatened. Therefore. their polarizing-cum-transformative politics tries to exclude groups seen as rivals from the political system and/or social and economic system. Whether its transformative goals tend to be inclusive or exclusive, however, polarizing politics tries to simplify politics. It simplifies the political spectrum in terms of Us versus Them, where “They” are labeled as the root source of the problems that the mobilizing group is facing. These “They” can be vaguely defined and include specific social or ideological groups as well as mainstream institutions – which can range from high judiciary and legislative bodies to media organizations – and these institutions’ decision-makers and supporters. The simplification of politics helps polarizing politics consolidate the ingroup and weaken opponents. Perhaps more interestingly and puzzlingly, it also, by simplifying politics that way, paralyzes the other group. The other group or groups are often put in a very difficult place, and don't know how to respond to this. Willingly or unwillingly, and by the way they respond to this polarizing politics, they end up deepening polarization. Which also leads to democratic decay more often than not.

McFaul: Well, let's get to the decay part in a moment. But, help me understand, where are the cleavages between ingroups and outgroups? Is it on ethnic terms? Or is it on economic terms? Or is it on a rural/urban divide? I'm guessing that in different countries it might be on different dimensions.

Somer: Absolutely, it changes from society to society. In every society there are certain important, deep cutting cleavages that we call formative rifts. These are recurring problems, recurring issues in a nation state’s history. They are certain tensions and conflicts that were created during the foundation of the state. To give you an example, in Bangladesh, during the foundation, the war that led to the independence of Bangladesh as a nation state from Pakistan, there was a division between groups who preferred unification and those who wanted to secede. From the very beginning, there was this discussion about who are the villains and who are the heroes of the national war, who was responsible for what, and the associated ideas regarding whether the national identity should be based on religious or linguistic belonging. So this became a deep cutting cleavage with an important secular-religious undercurrent.

To give another example, in the case of the United States, race became a formative rift. Even though of course there has been a lot of progress over time, it's a recurring theme. It was a conflict and trauma that emerged at the very beginning of the foundation of the United States and was reinforced by the Civil War. Perhaps the policies toward native Americans and women can be added. These formative rifts, however, do not automatically give rise to severe polarization. Politics always has some degree of polarization and formative rifts are often a part it. But they don’t override everything else. Polarization becomes really perilous, as we call it “pernicious,” if and when polarizing politics picks on a formative rift and activates it – or invents a new cleavage by combining several old ones – and succeeds in making it the basis of an Us vs. Them division overriding other cleavages.

Not all polarizing-cum-transformative politics become successful because they have to tap into the “right” existing division or construct a convincing new one that can become popular. It is not that easy to divide a society by saying “you are either with us or with them” because there are many cross-cutting cleavages. Two people may be separated by a left-right cleavage and have different positions vis-à-vis immigration, for example, but they will share many other things such as patriotism, gender, hobbies, or support of the same football team. In a nutshell, the sensitivities and expectations that underlie polarization are very important to understand how to find solutions, but it is also crucial to understand that they do not directly and by themselves cause polarization. Politics shapes which one of these grievances, or a combination of them, become the basis of a division that overrides everything else in terms of group interests, with what kind of a discourse and program, and the consequences for democracy.

McFaul: I see. Well, let's apply that analytic architecture you just outlined to what's happening here in the United States, for a moment. So do you see our current moment as a time of increased polarization in politics, with the election of Donald Trump?

Somer: Well, the case of US polarization has been a subject that people talked about and felt for a long time, since the 1970s. However, we also realize that with Trump it has been taken to a whole new level. So we may ask actually why?

McFaul: I think it's a great question.

Somer: The grievances and underlying cleavages are not all that new but the polarizing and simplifying politics that expresses them is. The discourse of the politics, especially the discourse that President Trump has been using, and, perhaps not so much his actual policies, but his attacks against the mainstream norms and institutions of U.S. politics are novel and unsettling. It is remarkably similar to other cases of polarizing politics in countries such as Turkey, Thailand, Venezuela, and others. The parallels are really interesting. Polarizing politics is really disruptive – which is instrumental to its transformative aims – because it defines politics as being in an abnormal, exceptional state. It claims that something is deeply not working in the way things are. In the case of the populist version of polarizing politics, this is usually the mainstream institutions and the mainstream elites. In the case of the U.S., the elites in Washington, and the so-called political and economic elites. Polarizing politics may also make claims with nativist undertones, maintaining that the original and pure versions of the system might have been good, but they have been corrupted later. If you define politics that way and can persuade large constituencies, first of all it is very disruptive and unsettling, because you're defining the very institutions and the very elites who are responsible for the normal functioning of the system like an enemy and as a problem. At the same time you're defining them as a barrier before improvement, progress and development. In which case, you're also implying that extraordinary political measures, or extraordinary discourses and actions would be justified. This suggests that people can, or rather should endorse political tactics and discourses that would be unacceptable in normal democratic politics, i.e. which violate the normal and accepted norms of democracy, which vilify opponents and institutions. In the eyes of many people, this kind of behavior becomes justified almost like in a battle. Even though American politics and society have been polarized for a long time, the fact that President Trump actually became the republican candidate for the presidency is very important. This created a lot of resistance, struggle and uproar within the GOP.

McFaul: What if he had failed? Would we be so focused on polarization? What if Jeb Bush had won? Would we be having this conversation?

Somer: As long as the opposition and American society as a whole don't really understand and address the transformative expectations underlying polarization, perhaps this level of polarization would have been postponed but it would have come back later.

McFaul: So here's the other paradox. I'm not an expert on American politics, but I follow them closely. And I worked for the previous president for five years. What's striking to me is, before Trump, the American people elected an African American, with a pretty funky name, by the way, twice. He did well in some states that then voted for Trump in 2016. In the three states that were pivotal to Trump's victory, President Obama carried them all. Even in my home state, which is considered a very conservative state, Montana, I think President Obama got 46%, 47% of the vote. So he didn't win the state, but he came very close. That suggest to me that maybe the voters aren't as polarized as our politicians, but it's a paradox. So help me understand the paradox. How could we have gone from this fairly moderate person in the Democratic Party, and then he loses votes to a candidate who seems almost entirely different from him. It's those switching of those voters that make Trump president.

Somer: Well, when Obama was elected, his motto was, "Yes, we can." In a way, he also promised a kind of transformative politics.

McFaul: Okay. So he himself back then was already pushing against the status quo.

Somer: Yes. However, he was trying to do this with a very different toolkit of policies and discourse. He did not use the populist and “other-vilifying” language that President Trump is using. So rather than asking the question, are voters as polarized as the elites are or vice versa? Perhaps we should ask the question, why are some voters, a significant segment of the American voters, receptive or potentially open to polarizing politics?

McFaul: Good point. That's a better question.

Somer: And the reasons may be rooted in expectations of fundamental change. The sources of these sentiments need to be found out. They may result from massive wealth and other inequalities and the inability of the established political system and institutions to find effective solutions. But people may not necessarily make sense of and articulate their problems in these terms, and different people will have different sensitivities. Politics is the force that frames and provides a name tag for existing problems, and it must offer policy solutions and an agenda for action. For the future of democracy and well-being, the critical question then is: what kind of politics will successfully respond to this need for fundamental change? We hope that a politics with a democratizing agenda, committed to democracy, will respond to this need. But if this kind of politics fails to respond, or to meet that demand, then authoritarian versions of polarizing-cum-transformative politics -- and a frequent version of that is populist, but there are many other versions of it -- will actually respond to this demand.

McFaul: And bring a breakdown of democracy.

Somer: In many cases we have seen that.

McFaul: Failing institutions. Well, let's pivot in that vein, to talk about Turkey. But do you see similar patterns there, as in the United States. Or are there different sources of polarization?

Somer: Similar patterns can be set in motion in otherwise highly dissimilar societies. In our work, we have so far examined eleven countries from across the world. But it seems to be equally common that people who are in the midst of these experiences tend to attribute them to dynamics that are particular to their own countries and cultures. Even though they give identifiably similar reactions to similar developments. They think that they are faced with unique problems, or they think that they are immune from outcomes other countries have suffered, such as democratic breakdown. So there has been a “Turkish exceptionalism” analogous to “American exceptionalism,” the idea that institutions and strengths unique to the U.S. would protect it from democratic erosion. Turkey was held as a flawed yet unique and promising example of democracy in a Muslim majority country bordering the Middle East. In addition to the country’s Ottoman legacy and strong national identity, the state institutions established during the late Ottoman modernization, Atatürk’s pro-secular reformation, and the transition to multiparty democracy were thought to be “exceptional” and robust. Despite many shortcomings and interruptions, a rather rigid secularism and electoral democracy had endured since 1950 and along with economic development Turkey was expected to consolidate liberal democracy in the 21st century. Against this backdrop, many welcomed the coming to power of the Justice and Development Party (AKP) at the end of 2002. It was rooted in political Islamism but had recently reinvented itself as a centrist party. They thought that the AKP could democratize rigid secularism, resolve the pious-secular “formative rift” and consolidate liberal democracy.

McFaul: That's Mister Erdoğan's party, right?

Somer: Yes, the current President, then Prime Minister, Mr Erdoğan's.

McFaul: There was a hope that that would be a good influence, that they were coming into the political system, the democratic system.

Somer: Because one of the shortcomings of Turkish secular democracy had been the relative exclusion of religious politics and the more pious segments of the society. This was a sentiment strong especially in provincial society. The AKP capitalized on these sentiments and public reactions against state corruption and economic crisis. When the party came to power with this background and through legitimate means, it was hoped that this would lead to more inclusion and develop Turkish democracy. Unfortunately, after fifteen years, the outcome has so far been the opposite. There has been a democratic breakdown. But this didn’t happen overnight. In order to confront the “strong” institutions that protected the constitution but also acted ideologically and prevented change, the AKP employed polarizing-cum-transformative politics. Institutions such as the pro-secular judiciary, professional bureaucracy, and praetorian military. 

In addition, there was also the rather unfathomable “deep state” elements. The AKP and its Islamist, and at the beginning also liberal-secular allies argued that for making Turkey a full democracy, for empowering the disadvantaged segments of society, one needed a disruptive type of politics. To change the rules of the game and create the “New Turkey,” you can be either with Us or with “Them,” they said, and declared the pro-secular institutions as “oligarchic elites.” For a while, this politics seemed to help overcome institutional resistance and expand democracy through legal and legitimate means. However, many didn’t realize that this discourse and extraordinary portrayal of politics was also justifying underhanded and illegal methods, which increasingly began to be employed by the government and its allies. The more they employed polarizing-cum-transformative politics, it also began to transform over time the AKP itself and its supporters in the media and civil society. Polarizing politics advantages a certain kind of politicians and other actors. Not necessarily people who want and benefit from the prevalence of reason and coexistence, but those who are skilled demagogues, willing to exploit divisions, and lacking any strong commitment to law, democratic principles, and truth. But this whole process was enabled and indeed even reinforced by the reactions of the opposition and institutions.

We may be observing some similarities between Turkey 10 years ago and the United States. When the opposition and institutional actors in Turkey were threatened by the AKP’s attacks against established norms and when they saw the incumbent party and leader saying and doing things that were not really legitimate, they were outraged, understandably. But in terms of what will happen to democracy and polarization in such a situation, everything depends on how the opposition will respond and react. Rather than concentrating on electoral mobilization by developing a constructive and programmatic response, which would address the popular need for change, they focused on trying to prevent the AKP’s ascendance and ways. They went to the judiciary to punish the AKP’s transgressions and they organized mass protests. When Mr. Erdoğan and the AKP used religion to berate the opposition by calling them “anti-religious,” they responded by trying to mobilize their constituencies by invoking their pro-secular sensitivities, calling Erdoğan’s voters “anti-secular or retrogressive.” By doing so they deepened polarization and consolidated the pro-Erdoğan bloc even further, who defensively closed ranks behind him. It would similarly be a mistake for the critics of Mr. Trump to focus on “anti-racism” and appear to call all Trump voters “racist.” Racism and bigotry must be fought for sure, but it may not be wise to make it and other identity issues the very basis of electoral mobilization. In addition, the opposition in Turkey targeted Erdoğan’s personal flaws.

McFaul: And all that just leads to more conflict.

Somer: And this further personalizes politics, which is really the opposite of what we want to see. Judicial institutions enforce democratic rules in normal times and can make crucial contributions to “near misses” of democracy during crisis times. But in severely polarized contexts, appealing to the judiciary carries risks such as signaling electoral weakness on the part of the opposition and ending up politicizing the judiciary. Another reaction, going to the streets and protesting may be sometimes necessary, but again, the question is whether it will be based on a positive program. Protesting alone may lead to a backlash from the supporters of the incumbent party, who may also mobilize in response. We saw this in Thailand for example. It also happened in Turkey. When polarization really deepens, after a while, it doesn't matter anymore who is right.

McFaul: It sounds like a vicious cycle, right? Back and forth.

Somer: Yes. So we may actually ask the question then, what can be done about it?

McFaul: Give me your top two or three ideas of what can be done.

Somer: The most important two takeaways may be that the kind of politics that can successfully challenge this polarizing, transformative and authoritarian politics might be another kind of polarization. But a constructive kind of polarization.

McFaul: Interesting.

Somer: A kind of polarization that doesn't capitalize on formative rifts, whatever these are in any particular country. It should draw on a programmatic response to socioeconomic problems and the need for change in society. So rather than presenting an either/or choice to the society in terms of personalities and oppositional identities, it should create a choice between policies.

McFaul: Okay, interesting.

Somer: Finally, I think because these policies need to respond to an underlying need for change in society, they should represent a new program and type of politics. Drawing on well-known discourses, solutions and ways of mobilization would be seen as pro-status quo. It should really be a response, and a constructive and feasible response, to the need in society for transformative change.
 

On October 22, Thum Ping Tjin delivered a talk at Stanford on Singapore’s political development and evolution under the ruling People’s Action Party. Audio from the talk, along with a transcript, is now available on his website.