Immunizing the Body Politic

Want to promote democracy in Burma? Start by making sure people are well enough to vote.


In June 1999, the Kosovo conflict came to an end. The armed forces of Yugoslavia, controlled by Serbian nationalist leader Slobodan Milosevic, finally gave up on their attempt to force the republic to stay within Belgrade’s orbit. Kosovo’s population (and especially the 1.5 million Kosovar Albanians who made up the overwhelming majority) welcomed the peace. But they faced an uncertain future.

The most pressing challenge involved public health. Months of war and ethnic cleansing had taken their toll on basic health care. The fledgling Balkan state found itself caring for the needs of 1 million displaced people, many of them returning from far-flung locations after fleeing the fighting. (The photo above shows a Kosovar woman fleeing into Albania with her baby in April 1999.) Public infrastructure was in dismal shape; many hospitals, clinics, and pharmacies lay in ruins. Healthcare workers were in scarce supply, the result of Serb efforts to purge locals from all administrative posts. Studies estimated that as many as 20 percent of the population suffered from post-traumatic stress. Non-war-related mortality rates spiked to two or three times the pre-war rate. The reason was simple: the collapse of the health care system meant that many chronic diseases went untreated.

A war-riven society cannot rebuild with people who are sick, displaced, and demoralized. The NATO-led alliance correspondingly placed health relief in the center of its nation-building effort. With donor backing, the UN Kosovo mission orchestrated large infusions of food, medicine, and shelter. This effort saved many lives that otherwise would have been lost to starvation, disease, or exposure. UN-compiled data show that the international health relief effort in the decade following the Kosovo peace accord have sharply lowered rates of tuberculosis and infant mortality, two health trends directly traceable to conditions of poverty and war.

While the reconciliation process in Kosovo still remains tenuous, there can be little question that the West’s health-care assistance played a direct role in bolstering nascent democratic institutions and improving governance in the years since the war. Improved medical conditions allowed Kosovo communities to revive and stabilize. Health care can also help to build important political bridges. When he was crafting the political agreement that enabled Kosovo to declare independence, Martti Ahtisaari, the then-UN special envoy, was able to allay fears among Serbs within Kosovo by allowing them to establish aid links to Serbia for hospitals and schools.

It might come as something of a surprise, but there is another place in the world that could benefit dramatically from a comparable effort by the international community. Burma (Myanmar) is a nation similarly scarred by ethnic strife, authoritarian rule, and poverty. Yet in the course of the past year, Burma’s leaders have announced plans to move the country toward democratic rule. They have followed up by easing control over the media, allowing opposition leader Aung San Suu Kyi to participate in a pending parliamentary election, and releasing political prisoners. These changes have led the United States to restore diplomatic relations, and have prompted others to lift sanctions or expand aid. The resulting window offers an opportunity that should not be missed. If the regime allows the unhindered delivery of health aid, such assistance can have an impact beyond that of merely helping people to overcome sickness. It can also boost support for reforms and reinforce the constituency for freedom.

There is much damage to repair. The previous military regime transformed Burma into a "barricade state," a country that shut down domestic political competition and shut out the international community. While defense spending consumes an estimated 25 percent of Burma’s budget, the generals’ appetite for weapons has left its people with health spending that amounts to just $2 per person per year. As a result, Burma today has some of the highest rates of HIV/AIDS, tuberculosis, and infant and child mortality in Southeast Asia. The UN Development Program gave Burma a ranking of 149 out of 187 countries on its human development index. Meanwhile, just as in Kosovo in 1999, refugees from Burma’s internal conflicts are likely to start making their way home, a process that is already driving demands for additional food, shelter, and medicine.

In 2002, when I was serving as the special U.S. ambassador on HIV/AIDS and global health for then Secretary of State Colin Powell, I was granted special permission to enter Burma on a quiet diplomatic mission to explore whether conditions were ripe for health aid. After cautious talks with the regime’s officials, I met with Aung San Suu Kyi, under heavy surveillance, to convey the message of American support and to solicit her views on health aid. She was adamant: Any international health assistance had to be distributed directly to non-governmental organizations, bypassing the government, which could turn the aid to its own uses rather than helping the populace.

As it happened, the political and diplomatic conditions soon deteriorated yet again, foreclosing a major health assistance effort. And for the moment, most of the major Western powers are sticking with sanctions, waiting to see the outcome of the April 1 parliamentary by-election in which Aung San Suu Kyi and other members of her party are running for seats. Even if the election is shown to be free and fair, it will still take months for sanctions to be lifted. Over the short and medium term, however, a concentrated health relief effort can get help to the needy even as it offers tangible evidence — to government officials as well as ordinary citizens — of the virtues of reform.

A staged approach that escalates aid in return for progress might start by allowing significantly more international aid organizations to operate in the country, a step that could be matched by more donor aid that flows through those organizations. By the government’s own count, only 29 international health organizations are present right now, a tiny number in a country of just under 60 million people. Meanwhile, in a hopeful sign, the government recently announced that it is reducing the amount of budget funds spent on the military and boosting spending for health and education. A relatively small number of foreign technical advisers could greatly boost the efficacy of that spending.

Allowing more food and medical businesses into the country can create steady jobs that lift more people out of poverty. More businesses and NGOs operating freely will give the government incentives to discuss public-private partnerships and other forms of cooperation. Broadening participation in social assistance efforts can diversify responsibilities away from the government, allowing citizens’ concerns to have greater voice and impact.

Opening the media to health promotion messages, including those aimed at those groups enduring stigma and discrimination from HIV/AIDS, can curtail the number of new infections among drug users and reduce the power of human trafficking rings. The airing of sensitive issues, such as drug use and sexual mores, may be discomfiting, but a free discussion of the factors that promote the spread of disease would encourage those who are ill or at risk to seek care and even demand it of the government. At the same time, these messages can help to promote acceptance and even empathy for a broad range of Burma’s ethnic groups and social strata.

Health assistance also offers opportunities for the improvement of governance. International supervision to protect aid flows from corruption can improve delivery as well as building overall momentum for reform. If international assistance programs are allowed to operate with safeguards against graft, the result is a classic win-win situation: The donors get more aid to the needy and the government can demonstrate its concern for the welfare of the citizenry.

The creation of an environment in which healthcare businesses, NGOs, and free media can operate boosts democratization by offering alternative, competing channels to the government. By allowing more market entrants who are willing to provide goods and services, the government reduces its own burdens. This is not entirely a matter of altruism. Government officials win when citizens are able to work, pay taxes, feed their families, and treat more illness on their own. At the same time, improving health will inevitably raise expectations. Helping people to overcome sickness gives them the chance to look beyond sheer survival and to begin claiming democratic values of open and diverse expression, just distribution of opportunity, and citizen rights.

Former UN general assembly president and Swedish diplomat Jan Eliasson recently told me that he wished he had more health resources as "a tool by his side" when he led talks confronting the Darfur humanitarian crisis in Sudan. Eliasson viewed negotiating the provision of tangible human needs such as water and medicines as a way to secure multi-party cooperation — a prerequisite for long-term political reconciliation. His remarks recall Colin Powell’s provocative description of humanitarian aid as a diplomatic "force multiplier" that, once deployed, can trigger a cascade of positive social and political side effects. Providing a health assistance package to Burma at this critical juncture has the potential to set off a series of mutually reinforcing accomplishments between the international community and the reform faction now at the helm of that government.

The concerted international efforts to restore Kosovo, along with other post-conflict nations, showed that public health intervention can promote the stable institutions that are a necessary precondition to political reconciliation. Similarly, responding to the urgent health needs of the population of Burma can give that long-suffering country a strong head start on the path toward democratization. After long years of international quarantine, a strong dose of well-managed health relief for Burma could be just the medicine that the country’s fledgling reform effort needs.

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