Southeast Asia’s megacities, long viewed as symbols of progress, are facing crises ranging from floods and ecological damage to displacement and widening inequality. Scholars of contemporary urban politics often attribute these predicaments to rapid globalization that originated in the mid-1980s. Yet APARC Visiting Scholar Gavin Shatkin argues they must be understood in the context of the Cold War era, when urban development agendas were molded by authoritarian regimes exerting political and economic control in the name of anti-communism.

Shatkin, an urban planner specializing in the political economy of urbanization and urban policy and planning in Southeast Asia, is a professor of public policy and architecture at Northeastern University. He recently completed his residency at APARC as a Lee Kong Chian National University of Singapore-Stanford fellow on Southeast Asia. Before heading to Singapore for the second part of his fellowship, he presented research from his new book project, which examines how U.S.-supported authoritarian regimes in Indonesia, the Philippines, and Thailand shaped urban politics in three megalopolises —Jakarta, Bangkok, and Metro Manila — during the 1960s and 1970s, with consequences that reverberate today.

Political Violence as Foundation

Shatkin refers to the period from the mid-1960s to the mid-1970s as Southeast Asia's "hot Cold War." During that time, in tandem with the armed conflict in Vietnam, Laos, and Cambodia, political violence spread through Indonesia, the Philippines, and Thailand, as the three countries witnessed the emergence of authoritarian regimes that cemented their rule by manipulating laws and institutions and deploying targeted, often extreme violence justified as necessary to combat communism.

In Indonesia, a U.S.-backed 1965 military coup, directed particularly at the Communist Party of Indonesia, led to the massacre of 500,000 to one million people, heralding General Suharto's 32-year authoritarian rule.

In the Philippines, amid leftist demonstrations and a communist insurgency, President Ferdinand Marcos declared martial law in 1972, marking the beginning of a decade defined by his administration’s widespread human rights violations, throughout which the United States continued to provide foreign aid to the country, considering Marcos a steadfast anti-communist ally.

And in Thailand, the imposition of the 1958 military dictatorship to counter communist threats and the 1976 crackdown by Thai police and right-wing paramilitaries against leftist protesters were pivotal points in establishing a royalist-nationalist model that defined "Thainess" (khwam pen thai) through loyalty to the monarchy, aligned with military power as well as American military aid and counter-insurgency policy guidance.

According to Shatkin, these were not isolated incidents but defining episodes of political violence that cemented authoritative oligarchic control over urban development. The explosive urbanization in Southeast Asian cities that followed in the mid-1980s must be read through the lens of this earlier period, when authoritarian regimes sought to exploit urban transformation to entrench political and economic power.

Oligarchic Politics

The Suharto regime's approach to Jakarta as a source of profit exemplifies this dynamic. Shatkin explains how, between 1985 and 1998, Indonesia's National Land Agency distributed land permits for extensive urban development across the Jakarta metropolitan region to a small network of oligarchic conglomerates, such as the Salim Group. These crony corporations, allied with Suharto through family ties and political patronage, came to dominate Indonesia’s economy. Many of these same corporate interests continue to influence development agendas in Jakarta today, owning exclusive rights to purchase and develop permitted land.

The same pattern of successive waves of government expansion of metropolitan regions through infrastructure development and the distribution of land to selected major conglomerates has repeated itself in Manila and Bangkok, creating in-country profit centers for economic interests and what Shatkin calls “an archipelago of exclusive gated elite spaces” that reinforces spatial dichotomy and segregation as each of these megacities also experiences a housing crisis.

For example, Shatkin’s research in Metro Manila during the late 1990s and early 2000s revealed that approximately 40% of the population lived in dense informal settlements. A significant portion of these residents were employed in the nearby container port, yet their wages were insufficient to afford legal housing near their workplace. This discrepancy highlights a structural dilemma where low-wage workers are effectively compelled to occupy land illegally.

Environmental crises in the three urban giants are also entrenched in political and social structures rooted in oligarchic and authoritarian legacies of the Cold War era, argues Shatkin. Thus, increasingly devastating floods in Jakarta, Metro Manila, and Bangkok have less to do with sea level rise and far more with the rapid spread of impervious surfaces and the extraction of groundwater resulting from uncontrolled urban sprawl on converted watershed lands within a relatively weak regulatory environment. Moreover, flooding mitigation solutions, like Indonesia’s Great Garuda seawall project, have perpetuated the same pattern of land giveaways to major developers.

Lessons from Urban Social Movements

Crucially, Shatkin's research shows that Southeast Asian urban activists themselves frame their struggles through the lens of Cold War legacies. For example, when Jakarta residents along the Ciliwung River faced eviction for flood mitigation in 2015, they challenged the Jakarta administration and the Ciliwung-Cisadane Flood Control Office in court, arguing the eviction was based on a Cold War-era law drafted during counterinsurgency operations that had no place in democratic Indonesia. They partially won the case.

In a similar vein, Thailand's Red Shirt movement, representing working-class people from the northeast, deliberately protested on land owned by the Crown Property Bureau, using iconography that critiqued the military-monarchy-elite alliance forged during the Cold War.

An example from Manila is the 2001 mass protests by urban, low-income groups in defense of President Joseph Estrada, who was impeached for corruption. Their support can be interpreted as a reaction against “anti-poor” discourse that originated in the Ferdinand Marcos era. For the urban poor, Estrada represented a powerful counterweight to this legacy of elite disdain.

"We need to listen to these protest movements on the ground,” says Shatkin. They do not primarily critique globalization but rather contest entrenched oligarchy and state paternalism forged by Cold War political violence. Thus, an alternative framework for understanding debates in urban politics of Jakarta, Manila, and Bangkok is to view them not merely as capitals shaped by globalization but as Cold War frontline sites.

Beyond Southeast Asia

The implications of Shatkin’s theoretical framework extend beyond Jakarta, Metro Manila, and Bangkok, and even beyond Southeast Asia. It illuminates how periods of political upheaval create enduring social, economic, and environmental inequalities.

Moreover, these three urban giants, which produce outsized shares of their nations' GDP, rank among the world's largest cities. Their futures will not only affect Southeast Asia but also global urban development patterns. Shatkin's work suggests that this future cannot be charted without reckoning with the past.

Addressing Inequalities in Health Care

Liang’s summer medical school project examined the prevalence of receiving annual eye screenings among South Korean adult patients with type 2 diabetes and how access to that care differed across demographic and socioeconomic groups over time. The goal was to investigate why screening rates for diabetic retinopathy, a complication of type 2 diabetes, remain low in South Korea, despite the country having universal health insurance coverage and guidelines that recommend annual eye screenings to prevent this leading cause of blindness.

He worked on this project with co-advisors Eggleston and Young Kyung Do, a professor in Seoul National University’s Department of Health Policy and Management and AHPP’s inaugural postdoctoral fellow. They found that lower-income patients with diabetes experienced barriers to quality diabetes care and had lower access to annual diabetes-related eye screenings.

For Liang, these results underscored a deeper lesson: even strong health systems with universal health insurance coverage have structural socioeconomic inequities that leave vulnerable groups behind. The findings helped solidify his conviction that improving health care requires more than clinical training alone. 

The project culminated in Liang’s presentation of the findings at the 2021 AcademyHealth Annual Research Meeting and spurred a new sense of purpose. ”It grew into a life-changing journey at Stanford,” Liang says.

That journey has led him to collaborate with researchers from around the world, particularly in Japan, Korea, and China, utilizing large-scale data to advance population health and applying population health methods to research topics ranging from maternal and child health to mental health, aging, and inflammatory skin diseases.

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Liang in South Korea. Photo courtesy of Richard Liang.

From Research to Health Policy Impact

Over the years, Liang evolved from a mentee of Eggleston into a collaborator on projects in Korea and elsewhere. As COVID-19 disrupted health services worldwide, he joined Eggleston and a team of researchers in studying the impact of the pandemic on chronic disease care in India, China, Hong Kong, Korea, and Vietnam. Their findings showed that marginalized and rural communities in those countries were hit especially hard, with negative consequences for population health that reached far beyond those directly infected with the virus.

He and Eggleston also co-authored a study on preferences for telemedicine services among patients with diabetes and hypertension in South Korea during the early COVID-19 pandemic. The research drew the attention of the Prime Minister’s Office in Korea, which used it to guide national policy on telemedicine, a field still lacking a formal legal framework in the country.

For Liang, it was proof of the available opportunities to make tangible improvements in population health by combining rigorous research with policy engagement and drawing on insights across medicine, public health, and the social sciences.

“As a medical student researcher with experiences across different East Asian countries, I witnessed firsthand many pressing challenges in health and society, from rapidly aging populations to rising rates of chronic diseases,” he says. “To tackle these issues holistically, there is a growing need to bring together diverse perspectives, but regional collaborations in medical and public health research have been scarce, and rarer still between the biomedical and social sciences.”

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Liang in China on a field visit during a 2025 summer seminar co-taught by Professors Eggleston and Williams. Photo courtesy of Richard Liang.

A Second Academic Home

Eggleston describes Liang as a model of interdisciplinary scholarship. In addition to medical school and doctoral research, he has carved out space to pursue his passion for East Asian studies. He has taken classes with APARC and affiliated faculty on topics ranging from health and politics in modern China to historical and cultural perspectives on North Korea, science and literature in East Asia, and tech policy, innovation, and startup ecosystems in Silicon Valley and Japan.

“The various classes and seminars I’ve attended through APARC, and subsequently as an East Asian Studies master’s student, have helped me think more critically about how the science and practice of medicine impact policy and society, and vice versa,” Liang says. Thanks to these experiences, he also found “a second academic home away from the medical school — a community that shares the recognition of the need to strengthen dialogue and cooperation across the Pacific and that actively encourages the interdisciplinary environment necessary to make my aspirations a reality.”

Most recently, he participated in a summer seminar on AI-enabled global public health and population health management, co-taught by Eggleston and Michelle Williams, a professor of epidemiology and population health at Stanford’s School of Medicine. Offered via the Stanford Center at Peking University, this three-week seminar focused on advancing global health through cross-cultural collaboration and the application of cutting-edge technology in population health and health policy decision-making. 

“During this program, I not only got to share my experiences from conducting population health research across East Asia, but also learn from and alongside fellow students across different disciplines, spanning from international relations to computer science,” Liang notes. He especially enjoyed meeting local Chinese graduate students and providing feedback and near-peer mentorship as an upper-year graduate student.

The seminar also led to exploring additional opportunities for research collaborations to study the implications of long-term annual health screenings across China. Liang, Eggleston, and Williams plan to expand this collaborative work.

Preparing to Become a Better Care Provider

Liang’s work across borders and disciplines not only advances research but also deepens the perspective of cultural humility he brings to his future role as a physician.

“The cross-cultural experiences and fruitful academic exchanges I’ve learned through as a Stanford graduate student not only inform my research in different countries, but also help prepare me to become a better care provider for my future patients,” he says.

For his achievements, Liang has earned multiple honors, including a Young Investigator Collegiality Award from the International and Japanese Societies for Investigative Dermatology, the Critical Language Scholarship in Korean from the U.S. Department of State, and the Stanford Center for Asian Health Research and Education Seed Grant.

He is looking forward to finishing medical school, attending a residency program, and continuing an interdisciplinary career that advances human health and well-being.

Reflecting on the fleeting nature of student life, his advice to fellow students is to remember that “Your time as a Stanford student can really fly by, so make sure to explore the opportunities that speak to you and offerings across the university, by organizations like APARC and the Freeman Spogli Institute for International Studies. The Bechtel International Center’s Office of Global Scholarships and the Hume Center for Writing and Speaking are also wonderful resources to get started.”

It is advice he has embodied himself, building a career at the intersection of medicine, public health, and East Asian studies, one project at a time.

As countries confront rising health care spending, policymakers everywhere face a key question: Who benefits from these spending increases?

Consider South Korea, a nation that has sharply increased its per capita health care spending over the past decade, delivering reasonable value in improving health outcomes as measured by rising life expectancy and a reduced overall disease burden. Yet, not all South Koreans reap equal rewards from the country’s health investments, according to a new study. Rather, adults in the lowest-income quintile receive the least health gains for every dollar spent on their care.

Published in the journal Health Affairs Scholar, the study reveals stark income-based disparities in the value of health care — defined as health gains relative to spending — among South Korean adults. The research systematically quantifies how efficiently health spending translates into longer, healthier lives across income groups in South Korea, providing insights into the distribution of health gains relative to health care spending.

“While earlier research often examined disparities in access, utilization, or outcomes separately, our analysis provides a more integrated assessment by jointly examining health care costs and health gains,” explains the research team, including Stanford health economist Karen Eggleston, the director of the Asia Health Policy Program (AHPP) at APARC. Eggleston’s co-authors are Sungchul Park, an associate professor in Korea University’s Department of Health Policy and Management and an incoming visiting scholar with AHPP; Young Kyung Do, a professor in Seoul National University’s Department of Health Policy and Management and AHPP’s inaugural postdoctoral fellow; and David Cutler, the Otto Eckstein Professor of Applied Economics at Harvard University. 

Their findings are sobering: between 2010 and 2018, South Korean adults in the lowest income quintile derived the least value from increased health spending compared to those in the middle- and higher income quintiles, suggesting a system that underserves the poorest population.

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Poorer Health, Smaller Gains

Between 2010 and 2019, per capita health care spending in Korea increased from $1,211 to $1,903, growing nearly 6 percent annually. During that decade, life expectancy climbed from 80.5 to 83.7 years, while disability-adjusted life years – expressed as the number of years lost due to ill-health – declined significantly. These measures seemingly suggest health spending has yielded solid returns in terms of improved health outcomes.

Yet stark income inequality persists in Korea. The country has both the highest old-age poverty rate and the largest share of out-of-pocket medical expenses among OECD countries. Does rising health spending benefit all segments of society equally?

To answer this question, the researchers analyzed trends in health spending and outcomes across income quintiles (excluding the bottom 10 percent of the household income distribution) from 2010 to 2018.

They measured health care spending as total medical expenditures, including costs for inpatient and outpatient services, emergency services, and prescription medications. All spending measures were adjusted for inflation and are reported in 2021 US dollars. To asses health outcomes, they used three indicators: (1) health-related quality of life, which relies on standard questionnaires to measure individuals’ perceived physical and mental health over time; (2) life expectancy, calculated using life table methods based on enrollment data from the national health insurance system; and (3) quality-adjusted life expectancy (QALE) at age 25, a measure that reflects both longevity and the quality of life during those years – an essential consideration when evaluating the effectiveness and equity of health care systems. To quantify the value of health care across income groups, the researchers applied statistical methods.

They found that adults in the lowest-income quintile experienced the smallest relative improvement in QALE over time: an increase of 0.7 years, compared with 1.4 years in the second and third quintiles, 1.3 years in the fourth, and 1.2 years in the highest quintile. Translated into a value estimate, adults in the lowest income quintile incurred $78,209 per QALE; in contrast, adults in the second through highest income quintiles achieved greater value estimates of $47,831, $46,905, $31,757, and $53,889, respectively. Thus, the most efficient gains in both longevity and quality of life were in the middle-income groups.

“We found that per capita spending was similar across income groups, but the lowest-income quintile experienced much smaller gains in QALE,” Eggleston and her collaborators write. 

Reflecting the principle of diminishing returns, “these findings highlight structural inequities in the South Korean health system and emphasize the need for targeted policies to promote equitable health care value.” 

Why Spending Does Not Equal Value

While the study did not identify causal pathways, secondary data suggest two plausible explanations for the results: poorer baseline health and greater unmet needs.

The data indicate that adults in the lowest-income quintile had significantly higher rates of chronic disease, disability, behavioral risk factors such as smoking and obesity rates, and mental health issues. These factors make it more difficult to achieve health gains.

Moreover, adults in the lowest-income quintile were less likely to receive preventive services, with markedly lower rates of medical checkups and cancer screenings. “Despite greater health needs, these adults faced persistent barriers to accessing care, particularly financial constraints,” the researchers say.

Notably, the highest value of health spending was not observed among adults in the highest-income group. One explanation is that this group may consume more low-value or marginally beneficial health services.

Policy Implications: Efficiency with Equity

Eggleston and her co-authors emphasize “the need for health policy in South Korea to prioritize both equity and value.” They highlight the following targeted strategies to improve efficiency and fairness:

• Invest in high-value services that link spending to meaningful health outcomes:
  • Improve access to high-value preventive and primary care services by expanding financial protections, particularly for lower-income groups.
  • Improve overall system efficiency by reducing the overuse of low-value health care services.
• Pair health care reform with broader social policies: Coordinate efforts to address upstream factors tied to health disparities, such as income inequality.
• Aim for improvements across the entire population: Implement evidence-based clinical appropriateness guidelines to ensure health care spending yields meaningful and equitable results.

While focused on South Korea, the study’s findings illuminate how income inequality interacts with health system designs and carry lessons for other countries.

“In countries with greater income inequality and fragmented health systems, such as the United States, disparities in health care value may be even more pronounced,” the co-authors write.

As South Korea and other countries continue to invest heavily in health care, the study highlights the urgency of improving the distribution and impact of that increased spending. Without focused reforms, it risks entrenching existing inequities rather than alleviating them.

This news entry was last updated on December 14, 2023.

APARC Communications Manager Michael Breger recently spoke with Dr. Soksamphoas Im, our Lee Kong Chian NUS-Stanford Fellow on Southeast Asia in fall 2023.

In this conversation, Im shares insights from her research on social welfare in Cambodia and how such public assistance is used by the ruling regime to establish legitimacy. You can listen to the interview on SoundCloud or read the audio transcript.

On November 29, 2023, Dr. Im presented her research at a seminar hosted by the Southeast Asia Program. You can view the event recording on our YouTube channel.

View a Japanese version of this announcement.

The Japanese public supports women’s advancement in society, finds the Stanford Japan Barometer, a survey platform launched by the Japan Program at Stanford University’s Walter H. Shorenstein Asia-Pacific Research Center (APARC). This result is somewhat surprising, considering Japan’s poor showing in global gender equality rankings.

Led by Professor of Sociology Kiyoteru Tsutsui, the Henri H. and Tomoye Takahashi Professor and director of the Japan Program at APARC, and Charles Crabtree, an assistant professor in the Department of Government at Dartmouth College and a former visiting assistant professor with the Japan Program, the Stanford Japan Barometer (SJB) is a periodic public opinion survey on political, economic, and social issues concerning contemporary Japan with three main parts: (1) questions about respondents’ demographic background; (2) a stable set of questions about support for policy issues, political parties, public institutions, and international entities; and (3) a thematically focused set of questions and experimental studies on topics of great relevance at the time of the survey. The survey is conducted with a national, quota-based sample of 8,000 Japanese residents.

In the first installation of the survey, conducted in late November 2022, the SJB examined issues concerning gender and sexuality in Japan. It found, among other results, that most Japanese are in favor of recognizing same-sex unions and support a legal change to allow married couples to keep separate surnames. The SJB also examined questions related to women’s advancement in Japanese society, the focus of the following report.

One prominent gender equality issue that often recurs in Japanese public discourse is women’s under-representation in prominent positions, especially in politics and business. According to the latest Global Gender Gap Report released by the World Economic Forum, Japan ranks 116th out of 146 countries in terms of gender equality. Japan fares well in the categories of Education and Health, but in Politics and Economy, it ranks 139th and 121st respectively. In another ranking on women’s role and influence in the workforce, the Glass-Ceiling Index compiled by The Economist, Japan ranks second-worst among the 29 developed countries surveyed. Japan barely avoided the lowest ranking (a dubious distinction taken by South Korea), but indeed ranks lowest in terms of the proportion of women in national parliaments (single or Lower House) among OECD countries, with only 10% of Lower House members being female.

To better understand this striking gender disparity, Tsutsui and Crabtree had respondents complete conjoint experiments that examined what types of candidates the Japanese public is more likely to support for a Diet seat and an external corporate board member. The results show, perhaps surprisingly, that Japanese people prefer women for these positions (52% to 48% for the Diet and 51% to 49% for corporate board). Women support female candidates more than men, but men also prefer female candidates over male ones, averaging across all other candidate characteristics such as education and occupational background. These differences are fairly stable across different ages, educational and family backgrounds, and political party support. Contrary to what gender representation in politics and corporate leadership would indicate, the SJB results suggest that there is robust support for women’s representation in those powerful positions across different spectrums of the Japanese public.

Tsutsui and Crabtree also asked a series of questions about views on gender roles and women’s advancement in Japanese society. Respondents were particularly supportive of more men taking parental leave and helping with childcare, registering 6.3 on a scale of 0-10 (5 being neutral and a number larger than 5 indicating support for the statement). They were not supportive of the statements about traditional gender roles, such as “Men should work outside the home and women should stay home” (3.8), or “Boys should be raised to be manly and girls should be raised to be womanly” (4.3). Interestingly, for all these questions, there is a statistically significant difference between male and female respondents, with men showing greater support for traditional gender roles, although the general trend is a shift away from traditional gender roles even among men.

On questions concerning women’s advancement in Japanese society, the Japanese public demonstrated strong support for the argument that more efforts should be made to increase the number of female politicians (5.8), executives (5.9), and board members (5.8). There is no substantial difference between men and women for these questions, indicating that the support for women’s advancement in politics and business is broadly shared across genders.

When it comes to using a quota to ensure women’s seats in the national Diet, management positions, and board rooms, the opinions are divided across the gender line, with women being significantly more supportive (5.1, 5.2, 5.2) than men (4.8, 4.7, 4.7). This likely indicates that men are threatened by the idea of quota as it would reduce the likelihood of their advancement toward these powerful positions.

Men’s resistance to quotas notwithstanding, overall, the Japanese public supports women’s advancement in society, perhaps recognizing the need for Japan to change in light of the embarrassing showing in global rankings of women’s empowerment. These results suggest that the slow pace of change in women’s advancement in Japan might be attributable to the behavior of gatekeepers, who are mostly older men who come from different socioeconomic backgrounds than the SJB’s average survey respondent, rather than to a lack of public support.

For media inquiries about the survey, please reach out to:
Noa Ronkin
APARC Associate Director for Communications and External Relations
noa.ronkin@stanford.edu