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.

Edited by SEAF Director Don Emmerson and co-published in 2008-09 by APARC at Stanford and ISEAS in Singapore, Hard Choices: Security, Democracy, and Regionalism in Southeast Asia continues to attract attention. Excerpted below are two differing but equally thoughtful recent reviews:

Noel M. Morada is a professor of political science at the University of the Philippines-Diliman and director of the Philippines Progamme in the Asia Pacific Centre for the Responsibility to Protect (R2P) at the University Queensland in Brisbane, Australia.

Writing in Kasarinlan: Philippine Journal of Third World Studies, 23: 2 (2008), pp. 119-122, Prof. Morada found the title of Hard Choices “apt” because its authors “ask hard questions—including philosophical ones—on the merits and demerits of pushing for a more ‘people-centered’ ASEAN, the challenges and constraints in implementing Responsibility to Protect (R2P) principles in the region, as well as the possible directions that ASEAN may take in the near future.”

A “good thing” about the book, in his view, “is that the reader is left to make his or her own conclusions” about “the issues and arguments” that it presents. He notes the variety of backgrounds of the authors: from scholars based far from Southeast Asia, through local analysts on Track II, to an official from inside the ASEAN secretariat itself. Their chapters, in his judgment, contribute significantly to current debates about what balance that ASEAN should strike between “state-centered and society-centered conceptions of security,” including “the dilemmas and constraints” that state and societal actors face in pursuing a more “participatory” kind of regionalism in Southeast Asia.

Among the issues featured in Hard Choices, Morada cites “the thorny problem of intervention in the domestic affairs of [ASEAN] members,” including the challenge to regionalism posed by Myanmar’s rulers, and whether or not the ASEAN Charter can facilitate a response or may itself be an obstacle to reform. While highlighting the relative optimism of Mely Caballero-Anthony’s chapter on non-traditional security, he finds a consensus among the book’s authors that “ASEAN’s traditional norms—i.e., state sovereignty and non-interference—still rule.”

Prof. Morada ends his review thus: “This should be a required reading for graduate students specializing in Southeast Asia and a must have for ASEAN specialists and observers. More importantly, civil society groups would benefit immensely from reading this volume as part of their education about ASEAN, on which many remain uninformed. Many of my friends in the academic community in the region have in fact been quite disappointed with many civil society groups who simply want to push their agenda but have not done their homework on the workings of ASEAN. This book should help enlighten them further.”

Lee Jones is a lecturer in the Department of Politics at the College of Queen Mary, University of London.

Writing for a future issue of the ASEASUK Newsletter, a publication of the Association of Southeast Asian Studies in the United Kingdom, Dr. Jones, unlike Prof. Morada, misses a firmer editorial hand. “Theoretical engagement is relatively sparse,” writes Jones, “and the book would have benefited from an overarching framework to help structure and guide the contributions. Particularly given many contributors’ focus on Myanmar, ASEAN’s policies towards it, and ASEAN’s recent institutional evolution, an early chapter agreeing [to] a collective account of these matters would have left more space for analysis and argumentation.”

Jones singles out the chapter by “veteran official Termsak Chalermpalanupap” as “a highly informative overview of ASEAN’s institutional development which will be useful for all students of ASEAN.” Chapters by Simon Tay (on air pollution) and Michael Malley (on nuclear energy) are also praised by Jones as demonstrating that “democratisation does not (as other contributors imply) automatically produce either more liberal policies or enhanced regional cooperation.” On the contrary, writes Jones, “democratisation can give vent to illiberal, nationalist and uncooperative sentiments, particularly when dominated (as ASEAN polities are) by cynical oligarchs. It is disappointing, therefore, that none of the chapters engages in systematic analysis of the domestic social forces at work in ASEAN states.”

“On balance,” for Jones, “the evidence in Hard Choices seems to favour the pessimist viewpoint. The basis for concluding that civil society has shattered elites’ monopoly on policymaking is rather weak. None of the pro-intervention authors sufficiently counter[s] the pragmatist challenge that ASEAN coherence could not withstand the adoption of a more liberal-interventionist posture. However, this is a contingent judgment which should not lead us simply to endorse the status quo. … [T] he fate of individual countries and the overall direction and content of ASEAN regionalism depends ultimately on the struggles of ASEAN’s own citizens.

Concludes Jones: “A clear-sighted analysis of the respective strengths and weaknesses of the force of movement and reaction, without succumbing to the defeatism of endorsing authoritarianism or the romanticism of believing that democratic institutions alone imply the victory of civil society (or that ASEAN can do much to create such institutions), is therefore vital for understanding the region’s prospects.”

Notices of the demise of Iran’s Green Revolution are premature. Without question, the tyrannical triumvirate — Ayotallah Ali Khamenei, President Mahmoud Ahmadinejad and the Revolutionary Guard — have dealt a crippling blow to the popular movement protesting their electoral coup of June 12.

Thousands of Iranians have been arrested and savagely tortured — from street protesters to election campaign organizers for Mir Hussein Moussavi, the likely victor in that contest. Many are now being forced to “confess” to having been agents of the United States or Britain.

We have seen this play before, not simply in Iran but in other tyrannies that suppressed mass movements for democratic change with massive violence and terror.

But Iran in 2009 is not China in 1989, Burma in 1990 or Belarus in 2006. The crisis in the Islamic Republic has exposed and widened massive cracks within the ruling elite. Such divisions are always a sign of an impending crackup of dictatorship.

Despite the rush to bury Iran’s reformist movement as another lost cause, Iran remains at a possible political tipping point. Democracies around the world have a duty — not simply to themselves, but to their strategic interests — to weigh in. They must not be deterred by threats to shun talks over Iran’s nuclear program.

President Obama has gotten it right by signaling America’s support for peaceful protest, human rights and the rule of law. More explicit language, not to mention action, would only play into the hands of the most cynical and vicious conservative elements in Iran. Moreover, with no diplomatic ties and all but no trade with Iran, there is little more the U.S. could do right now to pressure the regime.

But there are over 100 other democracies in the world. It is time that their voices were heard and their actions felt in Tehran.

Britain shares with the U.S. the handicap of a past history of negative interference in Iran. But Britain has diplomatic and economic ties to the regime, and breaking or suspending those will weaken Ayatollah Khamenei and his reactionary allies.

Moreover, Britain can have a unique kind of impact in Iran: For more than a century, Iranians have believed in the omnipotence of the “British hand” in the affairs of their country. Any indication that Britain is no longer willing to do business with the Islamic regime will hearten the Iranian people and undermine the regime’s aura of invincibility.

Germany, France and Italy are major trading partners with Iran. They have little history of colonial interference in Iranian affairs. Their decision to refuse to recognize the Ahmadinejad regime would have an immense effect. More compelling still would be a similar declaration from the entire Group of 8 at its impending summit.

The smaller and less powerful democracies can also have an impact. It would be preposterous for Iranian hardliners to attribute ulterior strategic motives to actions by the Scandinavian countries or the Netherlands, Ireland, Canada or Slovenia. If a coalition of such countries were to condemn the crackdown, call for a release of political prisoners and demand full respect for human rights — and back up these positions with a downgrading of diplomatic and trade ties — this would send a powerful message to both sides in Iran.

Many democracies around the world, including the above, have diplomatic ties with Iran. It is important that they maintain their embassies in Tehran. But they should now refuse to recognize the legitimacy of Ahmadinejad’s government.

The most powerful coalition of democracies in the world, the 27-member European Union, is now debating whether to withdraw their ambassadors from Tehran in protest over the detention of the British Embassy’s Iranian personnel.

The withdrawal of E.U. ambassadors would send a stunning message to the Iranian hardliners that coups and bloody suppression of peaceful protests carry a heavy price in international standing.

With the simple diplomatic act of denying legitimacy — something nearly all democratic forces in Iran are now asking of the world — the democracies of the world can give a needed boost to the forces of democratic change in Iran and earn the lasting gratitude of a movement that will eventually triumph.