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Global health disparities were the topic of a special event November 11th co-sponsored by the Asia Health Policy Program of the Shorenstein Asia-Pacific Research Center and the Center for Health Policy / Primary Care and Outcomes Research.

Sir Michael Marmot, internationally renowned Principal Investigator of the Whitehall Studies of British civil servants (investigating explanations for the striking inverse social gradient in morbidity and mortality), spoke about research on the social determinants of health and taking action to promote policy change. Pointing out the extreme disparities in life expectancy for peoples in different parts of the world – including the “haves” and “have-nots” within the high-income world – he presented an overview of “Closing the gap in a generation: Health equity through action on the social determinants of health” (http://www.who.int/social_determinants/en/). That report was commissioned by the World Health Organization (WHO) and released last year; Sir Marmot served as the Chair of the Commission on Social Determinants of Health.

Criticizing those who justify initiatives in global health solely on economic grounds, Sir Marmot argued that addressing the social determinants of health is a matter of social justice.

He presented data and discussed the report’s three primary recommendations: 1. Improve daily living conditions; 2. Tackle the inequitable distribution of power, money, and resources; and 3. Measure and understand the problem and assess the impact of action.
Stating that the World Health Assembly resolution on the social determinants of health was only meaningful as a first “baby step,” Marmot urged the audience to consider how research and policy advocacy can address the social determinants of health so that all individuals can lead flourishing lives.

Examples from Asia include

  • the high risk of maternal mortality (1 in 8) in Afghanistan;
  • the steep gradient in under-5 mortality in India (with the rate almost three times higher for the poorest quintile than for the wealthiest quintile);
  • less than half of women in Bangladesh have a say in decision-making about their own health care;
  • a large share of the world’s population living on less than US$2 a day reside in Asia;
  • social protection systems like pensions are possible in lower and middle-income countries, with Thailand as an example;
  • more can be done to address the millions impoverished by catastrophic health expenditures, such as in southeast Asia; and
  • conflict-ridden areas and internally displaced people, such as in Pakistan and Myanmar, are among the most vulnerable.

He also responded to questions about the role of freedom and liberty in social development – contrasting India and China – and commented on the peculiar contours of the US health reform debate.

Professor Marmot closed by noting that, in exhorting everyone to strive for social justice and close the gaps in health inequalities all too apparent in our 21st century world, he hoped he was not too much like Don Quixote, going around “doing good deeds but with people all laughing at him.” 
Professor Sir Michael Marmot MBBS, MPH, PhD, FRCP, FFPHM, FMedSci, is Director of the International Institute for Society and Health and MRC Research Professor of Epidemiology and Public Health at University College, London. In 2000 he was knighted by Her Majesty The Queen for services to Epidemiology and understanding health inequalities.

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The Asia Society has organized a Task Force on U.S. Policy toward Burma/Myanmar, co-chaired by retired U.S. Army General Wesley Clark and Holsman International Chair (and former USAID Administrator) Henrietta H. Fore.  The panel comprises a dozen or so individuals from various occupations and backgrounds, including SEAF's director, Donald K. Emmerson.  Assisting the Task Force is an also diverse Advisory Group of some thirty experts in Southeast Asian and other countries.  The Asia Society expects to release the Task Force's final report early in 2010.  

The timing of the study is of interest in view of the Obama administration’s willingness to meet with Myanmar’s rulers. 

America’s top diplomat on Asia is Assistant Secretary of State for East Asian and Pacific Affairs Kurt Campbell.  Deputy Assistant Secretary Scot Marciel covers Southeast Asian and ASEAN affairs.  In early November 2009 the two men traveled to Myanmar.  There they met not only with the iconic opposition figure and Nobel Prize winner Daw Aung San Suu Kyi, but also with Burmese Prime Minister Thein Sein.  The latter meeting was the highest-level contact between the two governments since 1995.  An even higher-level meeting was being planned for later in November at a US-ASEAN summit in Singapore, which would bring President Obama face to face with Myanmar’s head of state, Senior General Than Shwe.

Further enhancing the timeliness of the Task Force’s work is the announced prospect of national elections in Myanmar in 2010.  No independent observers expect the exercise to bring about anything resembling liberal democracy.  But some hold out hope that the balloting could yield a marginally more representative and accountable system. 

In early November 2009 it remained to be seen whether the current shifting of American policy toward dealing directly with the Burmese junta would prove effective in nudging its leaders toward political reform, or not. 

The Task Force’s report, scheduled for release early in 2010, should at least provide food for policymaking thought, as U.S. officials continue to review what has been and could be done with regard to a regime that has so far resisted both isolation and engagement.

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The coming to power of a new party in Japan, with a strong mandate to rule, is unprecedented in the postwar era. In the aftermath of the Japanese elections in August of this year, there has been much discussion, particularly in the Japanese media, about the foreign policy orientation of the new Democratic Party of Japan (DPJ)-led administration. Some commentators see an “anti-American” tilt—evidenced by differing views on the relocation of U.S. bases in Okinawa and the renewal of Japanese naval refueling operations in the Indian Ocean.

This viewpoint misses the foreign policy forest for its trees. The paradigm-shifting potential of this change lies much more in the DPJ’s desire to re-center Japan’s foreign policy on Asia. Across the spectrum of the DPJ, from former socialists on the left to those who came out of the conservative Liberal Democratio Party (LDP), there is broad agreement on the need to put much greater emphasis on Japan’s ties to the rest of Asia, particularly to China and South Korea.

The new Asianism in Japanese foreign policy was on display at the October 10 triangular summit of the Chinese, South Korean, and Japanese leaders, held in Beijing. It was only the second time these three have met on their own and the meeting was substantive, covering everything from coordinating on North Korea and economic stimulus policy to taking initial steps toward formation of a new East Asian Community. “Until now, we have tended to be too reliant on the United States,” Prime Minister Yukio Hatoyama told reporters after the meeting, adding that “The Japan-U.S. alliance remains important, but as a member of Asia, I would like to develop policies that focus more on Asia.”

The dominant foreign policy camp in Japan has been what Hitoshi Tanaka, a former senior foreign ministry official and close advisor to the DPJ, calls “alliance traditionalists,” whom he defines as those who “place the maintenance of a robust alliance with the United States above all other foreign policy priorities.” In the view of some DPJ policy advisors, the previous conservative governments mistakenly tried to cope with the challenge of a rising China by getting as close to the United States as possible. The decision to send troops to Iraq and the Indian Ocean was prompted not by any deep support for those causes but rather by the belief that this would ensure U.S. support in any tensions with China, and with North Korea.

All this took place as Sino-Japanese relations descended into their most troubled phase in the postwar period, prompted by former Prime Minister Koizumi’s provocative visits to Yasukuni Shrine, which honors Japan’s war dead. High-level contacts with China were frozen, tensions rose over territorial issues in the East China Sea, and rising nationalism on both sides culminated in the outbreak of government-sanctioned anti-Japanese riots in 2005 and a Chinese campaign to block Japan’s permanent membership in the United Nations Security Council.

There was an attempt by Koizumi’s conservative successors to roll back some of these tensions. But those signals were always mixed with the persistence of anti-Chinese views and the powerful camp of rightwing nationalists in and around the LDP who cling to a revisionist view of Japan’s wartime role, some even indulging in a vigorous defense of Japanese imperialism.

In the view of DPJ policy advisers, this pseudo-containment strategy is doomed to failure. Given the increasing economic interdependence between the United States and China, and their overlapping strategic interests, the United States will never form an anti-China front. Japan cannot rely solely, these advisers argue, on the U.S.-Japan security alliance to deal with China’s bid for regional hegemony.

Nor can Japan afford to indulge fantasies of confrontation with China, given its own extensive ties to its economy and society. Rather, the greater threat, in the view of many Japanese analysts, is being abandoned by the United States through the formation of a U.S.-China “Group of Two” that effectively excludes Japan, or relegates it to second-level status in the region.

Japan, those policymakers argue, needs to preempt that threat by engaging Asia on its own—not only China, but the entire region, from India back to Korea. The DPJ’s own policy vision, articulated by Prime Minister Hatoyama, Foreign Minister Katsuya Okada, and party strongman Ichiro Ozawa, remains vaguely defined but has three clear elements:

  • The U.S.-Japan security alliance remains the cornerstone, but with limits.
  • Japan plays a leadership role in East Asian regionalism.
  • The “history” question must be resolved.

What does this mean? There should be little question, particularly after the initial meetings between the new government and the Obama administration, that the DPJ seeks to back away from the security alliance. Over the past fifteen years, the DPJ leadership has not only supported, but even led, the expansion of Japan’s security role, beginning with the passage of the 1992 law permitting Japanese participation
in peacekeeping operations and including the initial dispatch of naval forces to the Indian Ocean in response to 9/11. Though the DPJ has made commitments to reduce the U.S. presence in Okinawa, it is already realizing how difficult that is to accomplish; some kind of compromise on this issue is imminent. Similarly, Foreign Minister Okada’s visit to Afghanistan and Pakistan demonstrated a willingness to contribute, mostly through economic aid, to the security effort in both countries.

Prime Minister Hatoyama presented his somewhat romantic desire to reproduce the European experience to create an East Asian Community in September before the United Nations General Assembly. Hatoyama has indicated that he understands this is a long process, and has been careful to make clear that Japan has no intention of excluding the United States’ role in the region, nor the use of the dollar as a reserve currency. As Hatoyama put in his UN address:

Today, there is no way that Japan can develop without deeply involving itself in Asia and the Pacific region. Reducing the region’s security risks and sharing each other’s economic dynamism based on the principle of “open regionalism” will result in tremendous benefits not only for Japan but also for the region and the international community.

Given the historical circumstances arising from its mistaken actions in the past, Japan has hesitated to play a proactive role in this region. It is my hope that the new Japan can overcome this history and become a “bridge” among the countries of Asia.

I look forward to an East Asian community taking shape as an extension of the accumulated cooperation built up step by step among partners who have the capacity to work together, starting with fields in which we can cooperate—free frade agreements, finance, currency, energy, environment, disaster relief and more. Of course, Rome was not built in a day, so let us seek to move forward steadily on this, even if at a moderate pace.

DPJ policymakers advocate pursuit of an East Asian community as only one of a nest of regional structures, including a regional security system that might grow out of the Six Party talks on North Korea. They also embrace the idea of a Japan-U.S.-China strategic dialogue, based on their own perception that without the combined muscle of the United States and Japan, they cannot bring China to the table on a range of issues from energy to intellectual property.

The last element of the DPJ’s policy vision is to take another major step in clearing away the legacy of the wartime past. Hatoyama personally reaffirmed his government’s adherence to the statement on war responsibility issued by then Prime Minister Murayama in 1995, at the time of the 50th anniversary of the end of the war.

Hatoyama, Ozawa and others in the DPJ leadership are determined to confront the history issue in a way that eases tensions with China and South Korea and also closes doors backward. They will not only refuse to go to the Yasukuni Shrine but also want to remove the Class A war criminals whose “souls” are enshrined there by decision of the shrine authorities, to the consternation of the Emperor, among others. The DPJ led the hue and cry over the unapologetic revisionism of former Japanese air force chief of staff, General Toshio Tamogami, who wrote an essay justifying Japan’s colonialism and wartime aggression, including the attack on Pearl Harbor. Foreign Minister Okada has backed the creation of a joint history textbook by China, Japan and South Korea, based on the model followed by France and Germany. These are stances the LDP has been historically incapable of taking.

The DPJ draws some inspiration from the anti-imperial form of Asianism—“Small Nipponism”—championed by the late Tanzan Ishibashi, who served briefly as premier in the mid-1950s and who was allied to Hatoyama’s beloved grandfather, and former premier, Ichiro Hatoyama.

In the coming months, the Hatoyama government will have numerous opportunities to develop its new policies, particularly in the run-up to Japan’s hosting of the APEC summit next year. Undoubtedly, it will be difficult to implement in practice, but this new Asianism marks a clear turning point in Japan’s postwar foreign policy.

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Aims The prevalence of Type 2 diabetes mellitus (DM) has grown rapidly, but little is known about the drivers of inpatient spending in low- and middle-income countries. This study aims to compare the clinical presentation and expenditure on hospital admission for inpatients with a primary diagnosis of Type 2 DM in India, China, Thailand and Malaysia.

Methods We analysed data on adult, Type 2 DM patients admitted between 2005 and 2008 to five tertiary hospitals in the four countries, reporting expenditures relative to income per capita in 2007.

Results Hospital admission spending for diabetic inpatients with no complications ranged from 11 to 75% of per-capita income. Spending for patients with complications ranged from 6% to over 300% more than spending for patients without complications treated at the same hospital. Glycated haemoglobin was significantly higher for the uninsured patients, compared with insured patients, in India (8.6 vs. 8.1%), Hangzhou, China (9.0 vs. 8.1%), and Shandong, China (10.9 vs. 9.9%). When the hospital admission expenditures of the insured and uninsured patients were statistically different in India and China, the uninsured always spent less than the insured patients.

Conclusions With the rising prevalence of DM, households and health systems in these countries will face greater economic burdens. The returns to investment in preventing diabetic complications appear substantial. Countries with large out-of-pocket financing burdens such as India and China are associated with the widest gaps in resource use between insured and uninsured patients. This probably reflects both overuse by the insured and underuse by the uninsured.

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Japanese voters brought about a quiet revolution in the political life of the country in the August 30 election of the lower house of the parliament. In a historic election, Japanese voters brought to an end more than a half century of almost uninterrupted rule by the conservative Liberal Democratic Party. The opposition Democratic Party of Japan swept the election, gaining an overwhelming majority in the lower house to go with their coalition majority in the upper house. Three prominent scholars will analyze the election results, looking at how they fit into past developments, what it tells us about the evolution of Japan's political system and voter behavior, what this means for the emergence of competitive elections in Japan, and what the election may mean for the future of US-Japan relations.

Philippines Conference Room

Robert Weiner Assistant Professor Speaker Naval Postgraduate School
Ethan Scheiner Professor, Department of Political Science Speaker University of California, Davis
Kaoru (Kay) Shimizu Assistant Professor Speaker Columbia University
Daniel C. Sneider Associate Director for Research, Shorenstein Asia-Pacific Reserach Center Moderator Stanford Unviersity
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Although its people are mainly Muslim, Malaysia is notably diverse.  Many communities of faith live together in relative harmony.  Yet ethnic tensions and decades of authoritarian rule have undermined national unity and a sense of shared purpose.  Since the watershed election of 2008, a revived political opposition and an active civil society have increasingly challenged the divisive politics of race and religion in Malaysia.  But severe obstacles still thwart full democratization and genuine pluralism. 

In his talk, Nik Nazmi Nik Ahmad will analyze the complexities of Malaysia’s race-based political system, the prospects of the country’s multiracial opposition, and what these dynamics imply for the future of democracy in Malaysia.

Nik Nazmi Nik Ahmad was elected to the Selangor State Assembly in Malaysia in March 2008 as a candidate of the opposition People’s Justice Party (Partai Keadilan Rakyat).  His roles in Keadilan include membership in the party’s National Youth Executive Committee.  In 2006-08 he served as private secretary to Keadilan’s de facto leader at the time, Anwar Ibrahim. 

Nik Nazmi is a columnist at the Malaysian Insider and the founder of SuaraAnum.com, a web magazine for young Malaysians.  He has been widely published in, and interviewed by, Malaysian and international media.  He read law and earned his LLB (Honors) from King's College, University of London.  While in London he joined British Muslims in protesting the occupation of Palestine and the war in Iraq.  His undergraduate work was done at the UEM Foundation College in Selangor, where he was elected president of the Student Council.  His secondary education was at the Malay College of Kuala Kangsar, which has been called “the Eton of the East.”  During his student career, he was active in multiple extra-curricular settings, including Muslim and social-service organizations and English-language debating teams.  He was born in Malaysia in 1982.

Daniel and Nancy Okimoto Conference Room

Nik Nazmi Nik Ahmad Selangor State Assemblyman and Political Secretary to the Chief Minister of Selangor, Malaysia Speaker
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In April, China announced an ambitious health care reform plan that aims to provide universal access to basic care for all Chinese while enhancing population health initiatives, strengthening service delivery, improving risk pooling, and significantly increasing government funding for the health sector. China Radio International interviewed Karen Eggleston, Asia Health Policy Program Director, about China's health care reform for the radio program "People in the Know." The program, aired on August 21, can be heard online.
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In the early 1990s, Japanese reformers promised a political transformation: fewer pork-barrel projects, more accountability, and greater transparency. Have these promises been realized?

In the past twenty years, Japanese politics has undergone many dramatic changes. Electoral reform altered the relationship between politicians and voters, and Japan has steadily moved toward a two-party system.

Amid these shifts, it remains unclear where Japanese politics is heading, and whether the changes we observe now will stand the test of time. Each chapter in this wide-ranging volume addresses a key political development in Japan, notably voting behavior, the relationship between politicians and bureaucrats, gender gaps in political candidacies, and clientelistic versus ideological politics. Political Change in Japan likewise includes extensive discussion of former Prime Minister Junichiro Koizumi's dramatic career. In sum, the book's contributors assess not only the direction but also the probable permanence of political change in Japan.

Intended for scholars and students who study Japan, this timely volume provides valuable reading for comparative political scientists as well. With contributions from some of the most eminent scholars working on Japan today, Political Change in Japan seeks to answer the question: Was political reform in Japan a revolution or a flash in the pan?

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Kaoru (Kay) Shimizu
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