Larry Diamond discusses the Chinese Communist Party’s range of influence and interference activities that target the public, civic, and social institutions of democracies, including subnational governments, universities, think tanks, media, corporations, and ethnic Chinese communities. Listen here.
Thirty years ago this week, I watched the news from Beijing and started shredding my bedding. It was the night before my college graduation, I had been studying Chinese politics, and news had broken that college students just like us had been gunned down in Tiananmen Square after weeks of peaceful and exhilarating democracy protests—carried on international TV. In the iconic square where Mao Zedong had proclaimed the People’s Republic decades before, bespectacled students from China’s best universities had camped out, putting up posters with slogans of freedom in Chinese and English. A “goddess of democracy” figure modeled after the Statue of Liberty embodied their hopes—and ours—for political liberation in China.
On my campus back then were just a handful of students majoring in East Asian studies. Learning of the brutal crackdown in Beijing, we somehow found one another, gathered our friends, and stayed up making hundreds of white armbands for classmates to wear at commencement the next day. Grappling with the cold realities of the “real world” we were about to enter, we didn’t know what else to do. So we tore sheets and cried for what might have been.
The June 4, 1989, massacre was a horrifying spectacle that the Chinese government has sought to erase from national memory ever since. But, 30 years later, contemplating what might have been is more important than ever. In hindsight, Tiananmen Square serves as a continuing reminder about just how much China has defied, and continues to defy, the odds and predictions of experts. The fact is that generations of American policy makers, political scientists, and economists have gotten China wrong more often than they’ve gotten China right. In domestic politics, economic development, and foreign policy, China has charted a surprising path that flies in the face of professional prognostications, general theories about anything, and the experience of other nations.
As a 2018-19 Postdoctoral Fellow in Contemporary Asia at the Shorenstein Asia-Pacific Research Center, I have been working on my book manuscript Pathways to Power: Opposition Party and Coalition Building in Multiethnic Malaysia. The book examines the dilemmas faced by opposition parties in authoritarian regimes as they try to build electoral and political power. In this brief blog post, I’ll discuss the motivation for the book project, the main argument, and some of its findings.
Competitive authoritarian regimes, where opposition parties compete against powerful incumbents that skew political and electoral institutions in their favor, are the most common type of non-democratic regime today. As conceptualized by political scientists Steven Levitsky and Lucan Way, competitive authoritarian regimes feature the trappings of democracy, including regular elections and multiparty political competition, but with an electoral playing field that heavily favors the ruling government. Ruling powers in these regimes use a variety of tools to stay in power, including electoral fraud, targeted arrests or harassment of opposition leaders, and subtler strategies to divide and coopt potential opposition.
Nevertheless, opposition parties in such regimes sometimes succeed in growing substantial electoral support against the authoritarian odds. My book analyzes how and why some opposition parties are able to do so – and provides a novel explanation for the conditions under which opposition parties build broad-based and coordinated electoral challenges. I examine two key electoral strategies used by opposition parties: Individual strategies used by parties to win over new voters from the ruling government, and collective strategies, where opposition parties coordinate or build coalitions with each other in elections. Even as these two strategies allow parties to win over new blocs of voters away from the ruling government, I focus on the dilemmas that these strategies create for the opposition. First, parties face different constraints in trying to appeal to new voters while maintaining the issues and identities around which they mobilize core support. Second, individual and collective electoral strategies are in fundamental tension with each other. When parties coordinate with each other in elections, I argue that they are less likely to broaden their individual base of support. As a result, coordination and coalition building constrains the ability of individual parties to develop a broad base of support across territory and among new demographics.
The manuscript examines these dilemmas through tracing opposition party emergence and growth in Malaysia. Malaysia is an interesting and important case for several reasons. First, a single party, the United Malays National Organization (UMNO), dominated the country’s ruling coalitions from the country’s independence in 1957 until 2018. But against this backdrop of extraordinary stability, Malaysia’s opposition parties gradually built up electoral power to the point of unseating UMNO from national power for the first time in 2018. Second, Malaysia is a country of incredible diversity: Its largest ethnic group, the Malays, makes up about half of the population, and it contains significant ethnic minority populations of Chinese, Indian, and other indigenous groups. This made the challenges faced by the opposition even more pronounced as they sought to expand support across ethnoreligious lines while also building cross-cleavage coalitions. I draw on diverse evidence from my fieldwork in Malaysia, including in-depth interviews with party elites and leaders from all major parties, data on elections at the subnational and national level, as well as evidence from political campaigns, party congresses, and archival research.
The empirical chapters trace the strategies of four opposition parties: The Democratic Action Party (DAP), Pan-Malaysian Islamic Party (PAS), The People’s Justice Party (PKR), and The United Indigenous Party of Malaysia (Bersatu) in the period of 1999-2018 as they sought to respond to new electoral opportunities to scale up their support. I examine their varying attempts to expand their individual appeal, while showing how their increasingly coordinated electoral challenges paradoxically strengthened their reliance on existing ethnoreligious bases of support. I analyze how these strategies set the stage for their success in the 2018 elections, where three of these four parties won power and formed a new national government. Another empirical chapter brings the theoretical argument to bear on additional cases, providing an in-depth examination of three other cases of authoritarian regimes to demonstrate the generalizability of the argument beyond Malaysia.
The book seeks to make three contributions to the academic literature. First, it brings a new theoretical perspective to the study of political competition under authoritarianism that sheds light on the determinants of opposition party success and failure. Second, it provides evidence and analysis of the factors leading to Malaysia’s unprecedented transition of government in 2018. Finally, it provides new insights into a broader literature on party adaptation in multiethnic societies and the study of the relationship between opposition parties and democratic transition.
Please join Larry Diamond, Senior fellow at the Freeman Spogli Institute for International Affairs and the Hoover Institution for the launch of his latest book, "Ill Winds: Saving Democracy from Russian Rage, Chinese Ambition, and American Complacency."
Featuring a Panel Conversation with:
Zin Mar Aung
Burmese MP and political activist
Vladimir Kara-Murza
Russian journalist and anti-corruption crusader
Cara McCormick
CEO, Chamberlain Project, Co-founder/Co-leader of The
Abstract: Sound strategy requires alignment of ends, ways, and means. A significant gap in ends (the objectives to be achieved) and means (the resources to be applied towards that objective) result in risk and likely policy failure. Few policies over the last decade have had a wider gap between ends and means than Syria. Declared U.S. objectives – “Assad must go” – were not matched by the resources for achieving that objective nor considered thought as to how it might realistically be achieved. This situation has worsened in the Trump administration as the declared objectives have increased but the available resources and political commitment have decreased. McGurk will discuss Syria policy across both administrations based on his own experience leading the U.S. response to ISIS. He has traveled to Syria extensively and calls for an urgent realignment of ends and means to drawn down risk to the United States. The lessons to be drawn are then applied to other foreign policy challenges and offer a ready formula for assessing the declared objectives of U.S. policy. The talk will be based on McGurk’s recent article in the May/June issue of Foreign Affairs magazine.
Speaker's Biography: Brett McGurk is the Frank E. and Arthur W. Payne Distinguished Lecturer at the Freeman Spogli Institute and Center for Security and Cooperation at Stanford University.
McGurk’s research interests center on national security strategy, diplomacy, and decision-making in wartime. He is particularly interested in the lessons learned over the presidencies of George W. Bush, Barack Obama, and Donald Trump regarding the importance of process in informing presidential decisions and the alignment of ends and means in national security doctrine and strategy. At Stanford, he will be working on a book project incorporating these themes and teaching a graduate level seminar on presidential decision-making beginning in the fall of 2019. He is also a frequent commentator on national security events in leading publications and as an NBC News Senior Foreign Affairs Analyst.
Before coming to Stanford, McGurk served as Special Presidential Envoy for the Global Coalition to Defeat ISIS at the U.S. Department of State, helping to build and then lead the coalition of seventy-five countries and four international organizations in the global campaign against the ISIS terrorist network. McGurk was also responsible for coordinating all aspects of U.S. policy in the campaign against ISIS in Iraq, Syria, and globally.
McGurk previously served in senior positions in the George W. Bush and Barack Obama administrations, including as Special Assistant to President Bush and Senior Director for Iraq and Afghanistan, and then as Deputy Assistant Secretary of State for Iraq and Iran and Special Presidential Envoy for the U.S. campaign against the Islamic State under Obama.
McGurk has led some of the most sensitive diplomatic missions in the Middle East over the last decade. His most recent assignment established one of the largest coalitions in history to prosecute the counter-ISIS campaign. He was a frequent visitor to the battlefields in both Iraq and Syria to help integrate military and civilian components of the war plan. He also led talks with Russia over the Syria conflict under both the Trump and Obama administrations, initiated back-channel diplomacy to reopen ties between Iraq and Saudi Arabia, and facilitated the formation of the last two Iraqi governments following contested elections in 2014 and 2018.
In 2015 and 2016, McGurk led fourteen months of secret negotiations with Iran to secure the release of Washington Post reporter Jason Rezain, U.S. Marine Amir Hekmati, and Pastor Saad Abadini, as well as three other American citizens.
During his time at the State Department, McGurk received multiple awards, including the Distinguished Honor Award and the Distinguished Service Award, the highest department awards for exceptional service in Washington and overseas assignments.
McGurk is also a nonresident senior fellow in the Middle East Program at the Carnegie Endowment for International Peace.
McGurk received his JD from Columbia University and his BA from the University of Connecticut Honors Program. He served as a law clerk to Chief Justice William H. Rehnquist on the U.S. Supreme Court, Judge Denis Jacobs on the U.S. Court of Appeals for the 2d Circuit, and Judge Gerard E. Lynch on the U.S. District Court for the Southern District of New York.
Brett McGurk
Payne Distinguished Lecturer
Center for International Security and Cooperation
If voters in Ukraine elect television star Volodymyr Zelensky president Sunday, as seems almost certain, that should please the Kremlin, which in the course of supporting rebels in the eastern regions of Ukraine has made clear its dislike for incumbent Petro Poroshenko. Zelensky, a political neophyte who plays a teacher unexpectedly elected president in the TV show “Servant of the People,” handily won the first round of the election March 31. Polls suggest he will beat the president in the runoff by as many as 30 points, and to the Kremlin, he must seem like a much more malleable figure.
That doesn’t mean he will be. Champagne corks popped in Moscow in November 2016 when Donald Trump unexpectedly won, and he has been a major disappointment for Putin, who wanted a change in Washington’s Russia policy. Zelensky could foil the Russians in exactly the same way.
Zelensky has no policy track record. During the campaign, he avoided detailed platform proposals, media interviews or political rallies, preferring instead to let his TV persona define his image. He could make mistakes — huge mistakes — as president. But he is no dummy: He built a successful business empire, and he may not be as prone to manipulation as Putin would want.
Jamie O’Connell is a Lecturer in Residence at Stanford Law School. He teaches and writes on political and legal development and has particular expertise in law and development, transitional justice, democratization, post-conflict reconstruction, and business and human rights. Until 2018, he was a Senior Fellow of the Honorable G. William and Ariadna Miller Institute for Global Challenges and the Law at the University of California, Berkeley, School of Law, as well as a Lecturer in Residence, teaching both law and undergraduate students.
O’Connell has worked on human rights and development in over a dozen countries in Africa, the Americas, Asia, and Europe, under the auspices of the United Nations, local and international non-governmental organizations, and academic institutions. He co-founded International Professional Partnerships for Sierra Leone, a non-governmental organization that worked with the government of Sierra Leone to enhance the performance of its agencies and civil servants. Earlier in his career, O’Connell studied international business as a researcher at Harvard Business School, publishing numerous case studies. He has directed the Human Rights Clinic at the University of Sierra Leone and taught as a visitor at Harvard Law School and Columbia Law School. O’Connell clerked for the Honorable James R. Browning on the U.S. Court of Appeals for the Ninth Circuit and is admitted to practice in California (inactive status) and New York. In 2016-17, he was a visiting professor and Fulbright Senior Scholar at the University of Valencia (Spain) Faculty of Law.
Abstract: Ambassador Koster will address the following political-military issues during his lecture. How has the security environment in Europe evolved since 2014, with growing instability and insecurity in the North Africa and the Middle East, and an assertive Russia in the East? How has Europe and NATO reacted to these challenges? Policies, structures and capabilities have been adapted, but will it be enough to restore peace and stability in Europe ? How will the demise of the arms control architecture affect all of this in the years to come?
Speaker's Biography: Ambassador Timo S. Koster is a career diplomat at the Dutch Ministry of Foreign Affairs. As of November 2018, Mr. Koster assumed his position as Ambassador-at-large for Security Policy & Cyber. Prior to this, since 2012, he was Director for Defence Policy and Capabilities at NATO HQ in Brussels.
After finishing his law degree at the University of Amsterdam, Ambassador Koster joined the diplomatic academy of the Ministry of Foreign Affairs of the Netherlands in 1991. His first appointment was at the Royal Netherlands Embassy in Nairobi, Kenya. Back in The Hague from 1994, he served in several positions within the Ministry, including a stint as Private Secretary to the Minister for European Affairs, before moving to the Royal Netherlands Embassy in London, as Head of Economic Department, between 1998 and 2001.
In 2001, Ambassador Koster became Acting Director for European Integration at the Ministry of Economic Affairs, after which he served as a Project Director at the Ministry for Foreign Affairs. In 2003 Mr. Koster was appointed Deputy Ambassador at the Royal Netherlands Embassy in Athens, Greece. In 2008 he moved to Brussels where he served as Defence Advisor at the Netherlands Permanent Representation to NATO until 2012 when he moved to the position of Director Defence Policy & Capabilities in the NATO International Staff.
Ambassador Koster is affiliated to the Atlantic Council Washington DC as a non-resident Ambassadorial Fellow at the Brent Scowcroft Centre for International Strategy and Security.
Timo S. Koster is married with two sons and two daughters.
Timo Koster
Career Diplomat
Dutch Ministry of Foreign Affairs
No recording will be allowed during the program. RSVP required for admission. No walk-ins.
Experts talk about a new Cold War between China and the United States. The world’s two largest economies are in open trade conflict, engaged in technological competition and stoking geopolitical uncertainty. The Oksenberg Conference will explore the causes that underlie today’s intensified conflict between the United States and China. We ask: What has precipitated the confrontational approach that currently unites U.S. policy towards China? What is the future of our strategic competition in the technological, economic and security realms? If U.S.-China rivalry is allowed to escalate, what might its implications be for our international liberal order? If a “new” Cold War is forming, how might it follow or diverge from the “old” Soviet-era Cold War?
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The Oksenberg Conference, held annually honors the legacy of the late Professor Michel Oksenberg (1938–2001) who was a senior fellow at Shorenstein APARC and the Freeman Spogli Institute for International Studies. Professor Oksenberg also served as a key member of the National Security Council when the United States normalized relations with China, and consistently urged that the United States engage with Asia in a more considered manner. In tribute, the Oksenberg Lecture recognizes distinguished individuals who have helped to advance understanding between the United States and the nations of the Asia-Pacific.
Agenda
2:35-3:05 PM Conversation with Dr. Condoleezza Rice, former U.S. Secretary of State and National Security Advisor
3:05-3:30 PM Audience Q & A
3:30-3:45 PM Break
3:45-4:25 PM Panel discussion with Prof. David M. Lampton and Amb. Michael A. McFaul
4:25-5:00 PM Audience Q & A
Speakers
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David M. Lampton is Oksenberg-Rohlen Fellow and Research Scholar at FSI and affiliated with Walter H. Shorenstein Asia-Pacific Research Center (Shorenstein APARC). He also is the Hyman Professor of China Studies and Director of the China Studies Program at the Johns Hopkins School of Advanced International Studies (SAIS) Emeritus. Dr. Lampton's current book project is focused on the development of high-speed railways from southern China to Singapore. He is the author of a dozen books and monographs, including Following the Leader: Ruling China, from Deng Xiaoping to Xi Jinping (University of California Press, 2014, and second edition 2019) and The Three Faces of Chinese Power: Might, Money, and Minds (University of California Press, 2008). He has testified at multiple congressional and commission sessions and published numerous articles, essays, book reviews, and opinion pieces in many venues popular and academic in both the western world and in Chinese-speaking societies, including Foreign Affairs, Foreign Policy, The American Political Science Review, The China Quarterly, The New York Times, The Washington Post,and many others.
Formerly President of the National Committee on United States-China Relations, Professor Lampton consults with government, business, and social sector organizations, and has served on the boards of several non-governmental and educational organizations, including the Asia Foundation for which he served as chairman. The recipient of many academic awards, he is an Honorary Senior Fellow of the American Studies Institute of the Chinese Academy of Social Sciences, former Gilman Scholar at Johns Hopkins, and the inaugural winner of the Scalapino Prize in 2010, awarded by the National Bureau of Asian Research and the Woodrow Wilson International Center for Scholars in recognition of his exceptional contributions to America’s understanding of the vast changes underway in Asia.
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Michael McFaul is the Ken Olivier and Angela Nomellini Professor of International Studies in Political Science; Director and Senior Fellow at the Freeman Spogli Institute for International Studies (FSI); and the Peter and Helen Bing Senior Fellow at the Hoover Institution, all at Stanford University. He was also the Distinguished Mingde Faculty Fellow at the Stanford Center at Peking University from June to August of 2015. He joined the Stanford faculty in 1995. Professor McFaul is also an analyst for NBC News and a contributing columnist to The Washington Post.
Dr. McFaul served for five years in the Obama administration, first as Special Assistant to the President and Senior Director for Russian and Eurasian Affairs at the National Security Council at the White House (2009-2012), and then as U.S. Ambassador to the Russian Federation (2012-2014). He has authored several books, most recently TheNew York Timesbestseller, From Cold War to Hot Peace: An American Ambassador in Putin’s Russia. Earlier books include Advancing Democracy Abroad: Why We Should, How We Can; Transitions to Democracy: A Comparative Perspective(eds. with Kathryn Stoner); Power and Purpose: American Policy toward Russia after the Cold War (with James Goldgeier); and Russia’s Unfinished Revolution: Political Change from Gorbachev to Putin.
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Jean C. Oi is the William Haas Professor of Chinese Politics in the Department of Political Science and a Senior Fellow of FSI at Stanford University. She is the founding director of the Stanford China Program at Shorenstein APARC and is the founding Lee Shau Kee Director of the Stanford Center at Peking University. Professor Oi has published extensively on political economy and the process of reform in China. Her books include Zouping Revisited: Adaptive Governance in a Chinese County, co-edited with Steven Goldstein (2018); and Challenges in the Process of China’s Urbanization, co-edited with Karen Eggleston and Wang Yiming (2017); Rural China Takes Off (1999); Property Rights and Economic Reform in China (1999), co-edited with Andrew Walder; and State and Peasant in Contemporary China (1989). Professor Oi also has an edited volume, China’s Path to the Future: Challenges, Constraints, and Choices, co-edited with Dr. Thomas Fingar (forthcoming, Stanford University Press). Her recent articles include “Unpacking the Patterns of Corporate Restructuring during China’s SOE Reform,” co-authored with Xiaojun Li in Economic and Political Studies (2018); and “Reflections on 40 Years of Rural Reform,” in Jacques deLisle and Avery Goldstein, eds., Reform and Opening: 40 Years and Counting, forthcoming. Her current research centers on fiscal reform and local government debt as well as continuing SOE reforms in China.
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Secretary Condoleezza Rice is currently the Denning Professor in Global Business and the Economy at the Stanford Graduate School of Business; the Thomas and Barbara Stephenson Senior Fellow on Public Policy at the Hoover Institution; and a professor of Political Science at Stanford University. She is also a founding partner of RiceHadleyGates, LLC.
From January 2005 to 2009, Rice served as the 66th Secretary of State of the United States, the second woman and first African American woman to hold the post. Rice also served as President George W. Bush’s Assistant to the President for National Security Affairs (National Security Advisor) from January 2001 to 2005, the first woman to hold the position.
Rice served as Stanford University’s Provost from 1993 to 1999, during which she was the institution's chief budget and academic officer. As Provost, she was responsible for a $1.5 billion annual budget and the academic program involving 1,400 faculty members and 14,000 students. In 1997, she also served on the Federal Advisory Committee on Gender -- Integrated Training in the Military.
From 1989 through March 1991, Rice served on President George H.W. Bush’s National Security Council staff. She served as Director; Senior Director of Soviet and East European Affairs; and, Special Assistant to the President for National Security Affairs. In 1986, while an international affairs fellow of the Council on Foreign Relations, Rice also served as Special Assistant to the Director of the Joint Chiefs of Staff.
As professor of Political Science, Rice has been on the Stanford faculty since 1981 and has won two of the highest teaching honors – the 1984 Walter J. Gores Award for Excellence in Teaching and the 1993 School of Humanities and Sciences Dean's Award for Distinguished Teaching.
She has authored and coauthored numerous books, including three bestsellers, Democracy: Stories from the Long Road to Freedom (2017); No Higher Honor: A Memoir of My Years in Washington (2011); and Extraordinary, Ordinary People: A Memoir of Family (2010). She also wrote Germany Unified and Europe Transformed: A Study in Statecraft (1995) with Philip Zelikow; The Gorbachev Era (1986) with Alexander Dallin; and Uncertain Allegiance: The Soviet Union and the Czechoslovak Army (1984).
In 1991, Rice cofounded the Center for a New Generation (CNG), an innovative, after-school academic enrichment program for students in East Palo Alto and East Menlo Park, California. In 1996, CNG merged with the Boys and Girls Club of the Peninsula (an affiliate club of the Boys and Girls Clubs of America). CNG has since expanded to local BGCA chapters in Birmingham, Atlanta, and Dallas. She remains an active proponent of an extended learning day through after school programs.
Since 2009, Rice has served as a founding partner at Rice Hadley Gates, LLC, an international strategic consulting firm based in Silicon Valley and Washington, D.C. The firm works with senior executives of major companies to implement strategic plans and expand in emerging markets. Other partners include former National Security Advisor Stephen J. Hadley and former Secretary of Defense Robert M. Gates.
Rice currently serves on the boards of Dropbox, an online-storage technology company; C3, an energy software company; and Makena Capital, a private endowment firm. In addition, she is vice chair of the board of governors of the Boys and Girls Clubs of America; a member of the board of the Foundation for Excellence in Education; and a trustee of the Aspen Institute. Previously, Rice served on various additional boards, including those of: the George W. Bush Institute; the Commonwealth Club; KiOR, Inc.; the Chevron Corporation; the Charles Schwab Corporation; the Transamerica Corporation; the Hewlett-Packard Company; the University of Notre Dame; the John F. Kennedy Center for the Performing Arts; and, the San Francisco Symphony Board of Governors.
In 2013, Rice was appointed to the College Football Playoff Committee, formerly the Bowl Championship Series.
Born in Birmingham, Alabama, Rice earned her bachelor's degree in political science, cum laude and Phi Beta Kappa, from the University of Denver; her master’s from the University of Notre Dame; and her Ph.D. from the Graduate School of International Studies at the University of Denver.
Rice is a Fellow of the American Academy of Arts and Sciences and has been awarded fifteen honorary doctorates. She currently resides in Stanford, California.
Bechtel Conference Center 616 Serra Mall Encina Hall, Central, 1st Floor Stanford, CA 94305
David M. Lampton
<br><i>Oksenberg-Rohlen Fellow, FSI, Stanford University</i><br><br>
Michael A. McFaul
<br><i>Director, Freeman Spogli Institute for International Studies (FSI); Professor, Political Science, Stanford University; Senior Fellow, Hoover Institution </i><br><br>
Jean C. Oi (Moderator)
<br><i>Director, Stanford China Program; William Haas Professor of Chinese Studies, Stanford University</i><br><br>
Secretary Condoleezza Rice
<br><i>The Denning Professor in Global Business and the Economy, Stanford Graduate School of Business; The Thomas and Barbara Stephenson Senior Fellow on Public Policy, Hoover Institution; Professor of Political Science, Stanford University</i><br><br>
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.
“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.
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:
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;
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;
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.
