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Emerging infectious diseases pose new international security threats because of the potential to inflict harm upon humans, crops, livestock, health infrastructure, and economies. H1N1’s impact on the Mexican economy in 2009, for example, has been estimated at almost 1% of Gross Domestic Product.

In this colloquium, Professor Ear will discuss his research on health and security in Southeast Asia, focusing on surveillance systems for emerging infectious disease. The experience of Cambodia and Indonesia demonstrates that the technical and human sides of surveillance systems are complementary inputs. Awareness of political, economic, and cultural issues is critical if policy-makers are to build more effective systems.

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How does a corrupt government stop corruption? What if that government is democratic, and must cultivate the support of political parties that are themselves corrupt? Is fostering reform in such a political economy the equivalent of trying to make snow in hell?

These questions may be overstated, but the dilemmas they convey are all too real. Witness the storm of concern triggered by the recent resignation of the highest-profile reformist in Indonesia, Sri Mulyani Indrawati, from her linchpin job as minister of finance in a country that was ranked the most corrupt and the most democratic in Southeast Asia in 2009.

Sri Mulyani waged unremitting war on graft. Under her stewardship of the finance ministry, more than 150 of its personnel were dishonorably discharged. Nearly 2,000 more were otherwise punished for infractions. She led a vigorous campaign against tax cheats. Among them were rich and influential people who had grown accustomed to absconding with funds they owed the government.

Euromoney named her ‘finance minister of the year’ in 2006—a post she had only taken up the year before. In 2008 and again in 2009 Forbes magazine admiringly listed her among ‘the 100 most powerful women in the world.’ Correspondingly, on the heels of her resignation on 5 May 2010, Indonesian stocks and rupiahs fell.

Indonesian president Susilo Bambang Yudhoyono (SBY) was directly elected to that office in 2004 and, for a second five-year term, in 2009. As president he has opposed corruption and championed reform. Fatefully, however, in 2004 he chose a wealthy businessman, Aburizal Bakrie, to join his government as coordinating minister for the economy.

In 2006 in East Java, a Bakrie-controlled company using an unprotected drill while probing for gas may have triggered a mud volcano that would swallow more than a dozen villages and render more than 15,000 people homeless. In 2010 the volcano continued to spew an estimated 100,000 tons of mud daily onto the surface. Bakrie’s reputation for probity was not enhanced when, reportedly against Mulyani’s advice, he insisted on denying responsibility for the disaster. Instead he blamed an undersea earthquake that had struck off the south coast of Java, some 250 kilometers away, two days before the mud erupted. Opinions remain divided as to what caused what.

An unambiguously man-made crisis in 2008, the global financial meltdown, shrank the Jakarta stock market, Bakrie’s holdings included. Trading on the exchange was temporarily suspended. Bakrie urged his fellow cabinet member Mulyani to extend the suspension. She refused. He was furious. Her relations with him worsened further when she slapped travel bans on certain Bakrie company executives accused of tax evasion.

In 2009 Bakrie became chair of the Golkar Party. Toward the end of that year he led a fierce campaign in the Indonesian legislature against both Mulyani and another nonpartisan technocrat, Indonesian vice-president Boediono, for malfeasance related to the government’s decision in 2008 to rescue an ailing financial institution, Bank Century. The bailout may have prevented a spiral of withdrawals, and thus helped Indonesia weather the global crisis, but the effort cost far more than expected, and some of the infusions apparently benefited key depositors more than the bank itself.

Legitimate financial questions were soon superseded, however, by a thoroughly political effort on the part of politicians and their supporters opposed to Mulyani and her reforms to oust not only her but the vice-president as well. Mulyani’s and Boediono’s opponents included, in addition to Bakrie, others whose circumstancial links to corruption she had uncovered.

An anti-Mulyani case in point is the Justice and Welfare Party (PKS). Despite priding itself on upholding Islamic ethics and opposing corruption, the PKS rejected allegations that one of its legislators, Muhammad Misbakhun, could have been implicated in a fictitious Bank Century letter of credit for US $22.5 million. When, at the end of April 2010, Misbakhun was arrested and detained on a warrant signed by the national police official in charge of economic and tax crimes, PKS leaders accused the police of having an ulterior motive. The party had by then, in effect, joined the anti-Mulyani chorus.

Subjected to intense and prolonged criticism by these politicians in the glare of the media, Mulyani had ample reason to quit the spotlight, resign, and leave Indonesia. (On 1 June 2010 she will become a managing director of the World Bank in Washington DC.) But her long record of nonpartisan tenacity in the struggle against corruption makes it hard to believe that she simply lost her will to fight. For the time being it is impossible to rule out that she was sacrificed for the sake of a restoration of political comity between SBY and his opponents.

The irony is that Golkar and the PKS had joined with SBY’s Democrat Party to form a ruling coalition, to which they continue to belong. SBY had built that coalition with the expectation that its members, having joined the government, would support it, including its campaign against corruption.

That inclusive or ‘rainbow’ strategy was a triple failure. First, cabinet posts that might have been held by competent and ethical nonpartisans motivated by a desire for public service were allocated instead to partisans whose skills and motives, shall we say, varied. Governance suffered. Second, coalition-party leaders who were given ministerial posts in return for ensuring broad legislative backing for the government in the legislature either would not or could not deliver that support. Cooptation failed. Third, some ruling-team politicians, who might have at least stood back from the fray, instead jumped in, seemingly hoping to blunt the government’s efforts to diminish corruption and improve governance while protecting themselves and furthering their own careers. Discipline frayed.

Mulyani has resigned. Has Bakrie won?

In a recent conversation, an off-the-record analyst anticipated ‘more stability, which, in Indonesia, correlates inversely with reform.’ He could be wrong. But it may not be coincidental that on 6 May 2010, one day after Mulyani announced her resignation, SBY met with ruling-coalition leaders. Or that the meeting launched a Coalition Parties Forum whose daily activities will be led by none other than the chair of the Golkar Party, Aburizal Bakrie. Or that Bakrie reported that SBY had agreed that the Forum would not try to bind the coalition to a common position. Or that, again according to Bakrie, whereas previously the coalition parties were only asked to help safeguard the government’s policies, henceforth they would be asked to help determine them as well. Much will depend on Mulyani’s replacement as minister of finance, and on whether he or she is told to stop rocking the boat.

If Mulyani’s remarkable legacy is indeed erased, illiberal circles in Singapore may think, ‘We thought so. Democracy does thwart reform.’ But my own judgment in hindsight will be less sweeping.

Indonesia’s Democrat Party is still basically an extension of the appealing personality of SBY. Over the six years since he was first elected president, more time, energy, and resources could have been invested in deepening the roots and popularity of the party itself. Had those assets been so spent, the Democrats might have been able, in the legislative elections of 2009, to enlarge their contingent of lawmakers enough to be able to rule, not by the dubious grace of Sri Mulyani’s antagonists, but in SBY’s and his party’s own right—subject to democracy’s checks and balances, yes, but freed of the need to cobble together a coalitional rainbow of colors that clash.

Donald K. Emmerson heads the Southeast Asia Forum at Stanford University and is also the editor of Hard Choices: Security, Democracy, and Regionalism in Southeast Asia. (Stanford/ISEAS, 2008/9)

A heartening number of analysts helpfully commented on an earlier draft of this essay.  While protecting their privacy by not naming them, I am grateful to them.  Complementing my focus here on the politics of Sri Mulyani’s exit is the economic context ably reviewed by Arianto A. Patunru and Christian von Luebke in their ‘Survey of Recent Developments’ in the Bulletin of Indonesian Economic Studies, 46: 1 (2010, 7-31.)

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How does a corrupt government stop corruption? What if that government is democratic, and must cultivate the support of political parties that are themselves corrupt? Is fostering reform in such a political economy the equivalent of trying to make snow in hell?

These questions may be overstated, but the dilemmas they convey are all too real. Witness the storm of concern triggered by the recent resignation of the highest-profile reformist in Indonesia, Sri Mulyani Indrawati, from her linchpin job as minister of finance in a country that was ranked the most corrupt and the most democratic in Southeast Asia in 2009.

Sri Mulyani waged unremitting war on graft. Under her stewardship of the finance ministry, more than 150 of its personnel were dishonorably discharged. Nearly 2,000 more were otherwise punished for infractions. She led a vigorous campaign against tax cheats. Among them were rich and influential people who had grown accustomed to absconding with funds they owed the government.

Euromoney named her ‘finance minister of the year’ in 2006—a post she had only taken up the year before. In 2008 and again in 2009 Forbes magazine admiringly listed her among ‘the 100 most powerful women in the world.’ Correspondingly, on the heels of her resignation on 5 May 2010, Indonesian stocks and rupiahs fell.

Indonesian president Susilo Bambang Yudhoyono (SBY) was directly elected to that office in 2004 and, for a second five-year term, in 2009. As president he has opposed corruption and championed reform. Fatefully, however, in 2004 he chose a wealthy businessman, Aburizal Bakrie, to join his government as coordinating minister for the economy.

In 2006 in East Java, a Bakrie-controlled company using an unprotected drill while probing for gas may have triggered a mud volcano that would swallow more than a dozen villages and render more than 15,000 people homeless. In 2010 the volcano continued to spew an estimated 100,000 tons of mud daily onto the surface. Bakrie’s reputation for probity was not enhanced when, reportedly against Mulyani’s advice, he insisted on denying responsibility for the disaster. Instead he blamed an undersea earthquake that had struck off the south coast of Java, some 250 kilometers away, two days before the mud erupted. Opinions remain divided as to what caused what.

An unambiguously man-made crisis in 2008, the global financial meltdown, shrank the Jakarta stock market, Bakrie’s holdings included. Trading on the exchange was temporarily suspended. Bakrie urged his fellow cabinet member Mulyani to extend the suspension. She refused. He was furious. Her relations with him worsened further when she slapped travel bans on certain Bakrie company executives accused of tax evasion.

In 2009 Bakrie became chair of the Golkar Party. Toward the end of that year he led a fierce campaign in the Indonesian legislature against both Mulyani and another nonpartisan technocrat, Indonesian vice-president Boediono, for malfeasance related to the government’s decision in 2008 to rescue an ailing financial institution, Bank Century. The bailout may have prevented a spiral of withdrawals, and thus helped Indonesia weather the global crisis, but the effort cost far more than expected, and some of the infusions apparently benefited key depositors more than the bank itself.

Legitimate financial questions were soon superseded, however, by a thoroughly political effort on the part of politicians and their supporters opposed to Mulyani and her reforms to oust not only her but the vice-president as well. Mulyani’s and Boediono’s opponents included, in addition to Bakrie, others whose circumstancial links to corruption she had uncovered.

An anti-Mulyani case in point is the Justice and Welfare Party (PKS). Despite priding itself on upholding Islamic ethics and opposing corruption, the PKS rejected allegations that one of its legislators, Muhammad Misbakhun, could have been implicated in a fictitious Bank Century letter of credit for US $22.5 million. When, at the end of April 2010, Misbakhun was arrested and detained on a warrant signed by the national police official in charge of economic and tax crimes, PKS leaders accused the police of having an ulterior motive. The party had by then, in effect, joined the anti-Mulyani chorus.

Subjected to intense and prolonged criticism by these politicians in the glare of the media, Mulyani had ample reason to quit the spotlight, resign, and leave Indonesia. (On 1 June 2010 she will become a managing director of the World Bank in Washington DC.) But her long record of nonpartisan tenacity in the struggle against corruption makes it hard to believe that she simply lost her will to fight. For the time being it is impossible to rule out that she was sacrificed for the sake of a restoration of political comity between SBY and his opponents.

The irony is that Golkar and the PKS had joined with SBY’s Democrat Party to form a ruling coalition, to which they continue to belong. SBY had built that coalition with the expectation that its members, having joined the government, would support it, including its campaign against corruption.

That inclusive or ‘rainbow’ strategy was a triple failure. First, cabinet posts that might have been held by competent and ethical nonpartisans motivated by a desire for public service were allocated instead to partisans whose skills and motives, shall we say, varied. Governance suffered. Second, coalition-party leaders who were given ministerial posts in return for ensuring broad legislative backing for the government in the legislature either would not or could not deliver that support. Cooptation failed. Third, some ruling-team politicians, who might have at least stood back from the fray, instead jumped in, seemingly hoping to blunt the government’s efforts to diminish corruption and improve governance while protecting themselves and furthering their own careers. Discipline frayed.

Mulyani has resigned. Has Bakrie won?

In a recent conversation, an off-the-record analyst anticipated ‘more stability, which, in Indonesia, correlates inversely with reform.’ He could be wrong. But it may not be coincidental that on 6 May 2010, one day after Mulyani announced her resignation, SBY met with ruling-coalition leaders. Or that the meeting launched a Coalition Parties Forum whose daily activities will be led by none other than the chair of the Golkar Party, Aburizal Bakrie. Or that Bakrie reported that SBY had agreed that the Forum would not try to bind the coalition to a common position. Or that, again according to Bakrie, whereas previously the coalition parties were only asked to help safeguard the government’s policies, henceforth they would be asked to help determine them as well. Much will depend on Mulyani’s replacement as minister of finance, and on whether he or she is told to stop rocking the boat.

If Mulyani’s remarkable legacy is indeed erased, illiberal circles in Singapore may think, ‘We thought so. Democracy does thwart reform.’ But my own judgment in hindsight will be less sweeping.

Indonesia’s Democrat Party is still basically an extension of the appealing personality of SBY. Over the six years since he was first elected president, more time, energy, and resources could have been invested in deepening the roots and popularity of the party itself. Had those assets been so spent, the Democrats might have been able, in the legislative elections of 2009, to enlarge their contingent of lawmakers enough to be able to rule, not by the dubious grace of Sri Mulyani’s antagonists, but in SBY’s and his party’s own right—subject to democracy’s checks and balances, yes, but freed of the need to cobble together a coalitional rainbow of colors that clash.

Donald K. Emmerson heads the Southeast Asia Forum at Stanford University and is also the editor of Hard Choices: Security, Democracy, and Regionalism in Southeast Asia (Stanford/ISEAS, 2008/9).

A heartening number of analysts helpfully commented on an earlier draft of this essay.  While protecting their privacy by not naming them, I am grateful to them.  Complementing my focus here on the politics of Sri Mulyani’s exit is the economic context ably reviewed by Arianto A. Patunru and Christian von Luebke in their ‘Survey of Recent Developments’ in the Bulletin of Indonesian Economic Studies, 46: 1 (2010, 7-31.)

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The Stanford Humanities Center and the Freeman Spogli Institute for International Studies (FSI) are pleased to announce that four international scholars have been chosen to come to Stanford in 2010-11 as part of a jointly sponsored international program entering its second year. Nominated by Stanford departments and research centers, the international scholars will be on campus for four-week residencies. They will have offices at the Humanities Center and will be affiliated with their nominating unit, the Humanities Center, and FSI.

A major purpose of the residencies is to bring high-profile international scholars into the intellectual life of the university, targeting scholars whose research and writing engage with the missions of both the Humanities Center and FSI.

The following four scholars have been selected for the upcoming academic year.

  • Anies Baswedan, currently President of Paramadina University in Jakarta, is a leading intellectual figure in Indonesia. In 2008, the editors of Foreign Policy named him one of the world's "top 100 public intellectuals." As an advisor to the Indonesian government, he is a leading proponent of democracy and transparency in Indonesia, a creative thinker about Islam and democracy, as well as a charismatic leader in the educational field. He was nominated by the Abbasi Program in Islamic Studies.
  • Stephane Dudoignon is a political scientist/senior research fellow at the EHESS in Paris. He is one of the world's leading scholars of Muslim politics and societies from the Caucasus to Central Asia. He is the author of pioneering work on Muslim movements, including the historical study of Sufi networks from the Volga River to China, Muslim intellectuals' debates about gender, and modern Sunni revivalist movements in Eastern Iran. While on campus, he will give lectures on Islam in Eurasia and Iran, among other things. He was nominated by CREEES, the Center for Russian, East European and Eurasian Studies.
  • Monica Quijada is a high-profile public intellectual and historian of Spain and Latin America at the Consejo Superior de Investigaciones Cientificas (CSIC) in Madrid. Her engagement with the UN in Argentina (working with refugees) and her directorship of the investigation carried out in the late 1990s regarding Nazi activities during the Second World War and in post-war Argentina shows her commitment to the public space. She has written extensively on dictatorship, populism, and war and their effect on the public sphere in Argentina and Spain as well as on the relationship between nineteenth-century Latin American states and their indigenous populations. She was nominated by the History Department and the Center for Latin American Studies.
  • Patrick Wolfe is a historian at La Trobe University in Melbourne, Australia. He is a premier historian of settler colonialism, currently working on a comparative transnational history of settler-colonial discourses of race in Australia, Brazil, the United States, and Israel/Palestine. While at Stanford, he will give lectures based on his core work on Australia and also on his forthcoming book Settler Colonialism and the American West, 1865-1904 (Princeton University Press). He was nominated by the Bill Lane Center for the American West.

While at Stanford, the scholars will offer informal seminars and public lectures and will also be available for consultations with interested faculty and students. For additional information, please contact Marie-Pierre Ulloa, mpulloa@stanford.edu.

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In spring 2009, the Forum on Contemporary Europe (FCE) and the Division on Languages, Civilizations and Literatures (DLCL) delivered the first part of its multi-year research and public policy program on Contemporary History and the Future of Memory.  The program explored how communities that have undergone deep and violent political transformations try to confront their past.

Despite vast geographical, cultural and situational differences, the search for post-conflict justice and reconciliation has become a global phenomenon, resulting in many institutional and expressive responses. Some of these are literary and aesthetic explorations about guilt, commemoration and memorialization deployed for reconciliation and reinvention.  Others, especially in communities where victims and perpetrators live in close proximity, have led to trials, truth commissions, lustration, and institutional reform. This series illuminates these various approaches, seeking to foster new thinking and new strategies for communities seeking to move beyond atrocity.

Part 1: Contemporary History and the Future of Memory

In 2008-2009, this multi-year project on “History and Memory” at FCE and DLCL was launched with two high profile conference and speaker series: “Contemporary History and the Future of Memory” and “Austria and Central Europe Since 1989.”  For the first series on Contemporary History, the Forum, along with four co-sponsors (the Division of Literatures, Civilizations, and Languages, principal co-sponsor; the department of English; The Center for African Studies; Modern Thought and Literature; the Stanford Humanities Center), hosted internationally distinguished senior scholars to deliver lectures, student workshops, and the final symposium with Stanford faculty respondents.

Part 2: History, Memory and Reconciliation

In 2009-2010, we launch part 2 of this project by adding “Reconciliation” to our mission.  We are pleased to welcome the Human Rights Program at the Center on Democracy, Development, and the Rule of Law as co-sponsor of this series.  This series will examine scholarly and institutional efforts to create new national narratives that walk the fine line between before and after, memory and truth, compensation and reconciliation, justice and peace. Some work examines communities ravaged by colonialism and the great harm that colonial and post-colonial economic and social disparities cause.   The extent of external intervention creates discontinuities and dislocation, making it harder for people to claim an historical narrative that feels fully authentic.  Another response is to set up truth-seeking institutions such as truth commissions. Historical examples of truth commissions in South Africa, Peru, Chile, Argentina, Morocco inform more current initiatives in Canada, Cambodia, Colombia, Kenya, and the United States.  While this range of economic, social, political and legal modalities all seek to explain difficult pasts to present communities, it is not yet clear which approach yields greater truth, friendship, reconciliation and community healing.  The FCE series “History, Memory, and Reconciliation” will explore these issues.

The series will have its first event in February 2010. Multiple international scholars are invited.  Publications, speaker details, and pod and video casts will be accessible via the new FSI/FCE, DLCL, and Human Rights Program websites.

Series coordinators:

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Donald K. Emmerson is a professor at Stanford University, where he heads the Southeast Asia Forum in the Shorenstein Asia-Pacific Research Center in the Freeman Spogli Institute for International Studies and is affiliated with the Abbasi Program in Islamic Studies and the Center on Democracy, Development, and the Rule of Law. 

Prior to joining Stanford’s faculty, Emmerson taught political science at the University of Wisconsin-Madison and spent time as a visiting scholar at the Australian National University (Canberra), the Institute of Advanced Studies (Princeton), and the Woodrow Wilson International Center for Scholars (Washington, DC), among other institutions.  He received his Yale University PhD in political science following a Princeton University BA in international affairs.

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At Stanford, in addition to his work for the Southeast Asia Program and his affiliations with CDDRL and the Abbasi Program in Islamic Studies, Donald Emmerson has taught courses on Southeast Asia in East Asian Studies, International Policy Studies, and Political Science. He is active as an analyst of current policy issues involving Asia. In 2010 the National Bureau of Asian Research and the Woodrow Wilson International Center for Scholars awarded him a two-year Research Associateship given to “top scholars from across the United States” who “have successfully bridged the gap between the academy and policy.”

Emmerson’s research interests include Southeast Asia-China-US relations, the South China Sea, and the future of ASEAN. His publications, authored or edited, span more than a dozen books and monographs and some 200 articles, chapters, and shorter pieces.  Recent writings include The Deer and the Dragon: Southeast Asia and China in the 21st Century (ed., 2020); “‘No Sole Control’ in the South China Sea,” in Asia Policy  (2019); ASEAN @ 50, Southeast Asia @ Risk: What Should Be Done? (ed., 2018); “Singapore and Goliath?,” in Journal of Democracy (2018); “Mapping ASEAN’s Futures,” in Contemporary Southeast Asia (2017); and “ASEAN Between China and America: Is It Time to Try Horsing the Cow?,” in Trans-Regional and –National Studies of Southeast Asia (2017).

Earlier work includes “Sunnylands or Rancho Mirage? ASEAN and the South China Sea,” in YaleGlobal (2016); “The Spectrum of Comparisons: A Discussion,” in Pacific Affairs (2014); “Facts, Minds, and Formats: Scholarship and Political Change in Indonesia” in Indonesian Studies: The State of the Field (2013); “Is Indonesia Rising? It Depends” in Indonesia Rising (2012); “Southeast Asia: Minding the Gap between Democracy and Governance,” in Journal of Democracy (April 2012); “The Problem and Promise of Focality in World Affairs,” in Strategic Review (August 2011); An American Place at an Asian Table? Regionalism and Its Reasons (2011); Asian Regionalism and US Policy: The Case for Creative Adaptation (2010); “The Useful Diversity of ‘Islamism’” and “Islamism: Pros, Cons, and Contexts” in Islamism: Conflicting Perspectives on Political Islam (2009); “Crisis and Consensus: America and ASEAN in a New Global Context” in Refreshing U.S.-Thai Relations (2009); and Hard Choices: Security, Democracy, and Regionalism in Southeast Asia (edited, 2008).

Prior to moving to Stanford in 1999, Emmerson was a professor of political science at the University of Wisconsin-Madison, where he won a campus-wide teaching award. That same year he helped monitor voting in Indonesia and East Timor for the National Democratic Institute and the Carter Center. In the course of his career, he has taken part in numerous policy-related working groups focused on topics related to Southeast Asia; has testified before House and Senate committees on Asian affairs; and been a regular at gatherings such as the Asia Pacific Roundtable (Kuala Lumpur), the Bali Democracy Forum (Nusa Dua), and the Shangri-La Dialogue (Singapore). Places where he has held various visiting fellowships, including the Institute for Advanced Study and the Woodrow Wilson International Center for Scholars. 



Emmerson has a Ph.D. in political science from Yale and a BA in international affairs from Princeton. He is fluent in Indonesian, was fluent in French, and has lectured and written in both languages. He has lesser competence in Dutch, Javanese, and Russian. A former slam poet in English, he enjoys the spoken word and reads occasionally under a nom de plume with the Not Yet Dead Poets Society in Redwood City, CA. He and his wife Carolyn met in high school in Lebanon. They have two children. He was born in Tokyo, the son of U.S. Foreign Service Officer John K. Emmerson, who wrote the Japanese Thread among other books.

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In early spring, historic health reform passes, extending insurance to millions of uninsured. Despite problems with workplace-based coverage, controversy over government subsidies for insurance premiums, and disparities across a large and diverse nation, dramatic shift to a single-payer system was seen as impractical.

Instead, reforms focus on expanding current social insurance programs as well as new initiatives to cover the uninsured, improve quality, and control spending. They provide a basic floor, subsidized for the poorest, but preserve consumer freedom to choose in health care. No government body dictates choice of doctor or hospital; investor-owned and private not-for-profits compete alongside government-run providers like community health centers and rural hospitals.

Left to be addressed in later phases are the difficult questions of how to slow the relentless pace of health care spending increases -- driven in part by technological change and population aging, but also perverse incentives embedded in fee-for-service payment and fragmented delivery. Pushed through despite multiple crises confronting the leadership, the final landmark health reform works in conjunction with measures enacted as part of the fiscal stimulus package to strengthen the healthcare system. Some provisions take effect immediately; others will take many years to unfold.

President Obama’s triumph on his top domestic priority? Actually, there were no votes along partisan lines, no controversy over abortion. I am describing health reform in China, which was announced almost exactly a year ago.

We do not hear much about the parallels in the US and Chinese social policy. But we cannot fully understand each other if we ignore these commonalities. We do not hear much about those who, in both societies, have been rendered destitute merely because they or a family member became sick or injured in a system with a social safety net full of gaping holes.

It will surprise many Americans to know that government financing as a share of total health spending was lower in socialist China over the last decade than in the United States. Now China has pledged about US$124 billion over 3 years to expand basic health insurance, strengthen public health and primary care, and reform public hospitals.

In China, the injustice of differential access to life-saving healthcare had sparked cases of social unrest. The April 2009 reform announcement was the culmination of years of post-SARS (2003) soul searching for a healthcare system befitting China’s dynamically transforming society. Special interests block change. (Sound familiar?) The CPC Central Committee and the State Council acknowledge that successful health reform will be “an arduous and long-term task”.  

If the US can pass sweeping health reform despite an unprecedented financial crisis, and China can envision universal health coverage for 1.3 billion while “getting old before getting rich,” then together we should be able to look past our many differences to focus on our common interests. Our two proud nations must work together to confront numerous challenges, such as upholding regional stability (e.g. on the Korean peninsula); redressing global economic imbalances (increasing health insurance can help spur China towards more domestic consumption); and investing in “green tech” for a warming planet and “grey tech” for an aging society.

 

* * *

When searching for insights about how other countries deal with similar challenges, Americans often look to Europe and Canada. Rarer is the comparison to counterparts across the Pacific. Yet President Obama has clearly articulated the vision of the US as a Pacific Nation, and there are developments around the Pacific Rim that merit consideration in our debates.  

Australia pioneered cost-effectiveness in health care purchasing, while the US continues to debate whether cost should be part of comparative effectiveness research and policy decisions.

Both Japan and South Korea, like Germany, have enacted long term care insurance to smooth the transition to an aging society. Their experiences might be fruitful as we implement the first national government-run long-term care insurance program, a little-heralded component of the newly passed legislation (and a fitting legacy of Senator Edward Kennedy).

Japan and Singapore provide universal coverage to older populations than ours with health systems that, although surprisingly different from each other in terms of public financing and role of market forces, both ranked among the best in the world -- and far higher than the US -- in the World Health Organization’s ranking of health systems in the year 2000. Although one may quibble with the ranking, it is indisputable that Japan spends a much smaller share of GDP on healthcare than the US does, despite being one of the oldest and longest-lived societies in the history of the world and having (like the US) a fee-for-service payment system.

Japan and South Korea are also democracies, where health policies occasionally engender heated debates. In South Korea, physicians went on nationwide strike three times to oppose the separation of prescribing from dispensing. Although Japan’s incremental reforms rarely spur such drama, the passions aroused by end-of-life care – embodied in the bizarre “death panels” controversy in the US health reform debate of 2009 – has its counterpart in the bitter nickname for Japan’s separate insurance plan for the oldest old: “hurry-up-and-die” insurance.

Yet Japan, Singapore, and Hong Kong all offer health systems that provide reasonable risk protection and quality of care for populations older than ours, with a diverse range of government and market roles in financing and delivery, while spending far less per capita than the US.

No system has all the answers. But the US and our neighbors across the vast Pacific have a common interest in sharing what we’ve found that works for health reform. Despite divergence in our political and economic systems, we all value long, healthy lives for ourselves and our children -- and we’re united in health reforms that try to further that goal.

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