Democracy Lab

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.



We Need to Talk to Iran, But How?

Thirty-two years of sanctions and bluster haven't worked. It's time to try something different.

It was easy enough to miss amid all the chest-thumping, threats, and talk of imminent strikes filling the airways, but last week, Iran signaled its willingness to restart talks with the P5+1 (the five U.N. Security Council members plus Germany) about its nuclear program. "We hope the P5+1 meeting will be held in near future," Iranian Foreign Minister Ali Akbar Salehi said, as a group of inspectors from the International Atomic Energy Agency (IAEA) toured the country.

The last round of such talks ended inconclusively in Istanbul in January 2011, and it has taken more than a year to get close to a new meeting. Although no date has been set for the new talks, it's not too early to begin planning for how to make them more productive than past negotiations. Here are a few steps that could put us on a road more promising than the current ominous exchanges.


It is tempting to dismiss the current talk of war as bluff and bluster. Although there is certainly much hot air in the current talk of Iran's closing the Strait of Hormuz or of imminent Israeli attacks on Iran, its very volume and frequency should make us worry. Each threat, each warning, each "red line" declared threatens to trap the parties in rhetorical corners. Even worse, a party might start believing its own defiant rhetoric and fail to distinguish between real and imaginary threats.

Complicating the issue is the fact that the United States and Iran have almost never spoken officially to each other in more than 30 years. Diplomats do not meet; officials do not talk; and military officials to not communicate. Instead of contact in which each side can listen to the other, take the measure of personalities, and look for underlying interests behind public positions, each side has imputed the worst possible motives to the other, creating an adversary both superhuman (devious, powerful, and implacably hostile) and subhuman (violent, irrational, and unthinking).

This mutual demonization -- born of fear and contempt -- raises the risk that a simple confrontation will lead to miscalculation and full-scale conflict. Put simply, today, in the absence of direct communication, it would be very difficult to de-escalate a potential incident in the Persian Gulf or Afghanistan. With each side assuming the worst about the other, a minor incident could lead both sides into military and political disaster.


Current events are not running in Iran's favor, despite its bombastic rhetoric. The overthrow of longtime despots in Tunisia and Egypt raised an obvious question for Iranian leaders: "Why not here?" Iranians chanted in the streets, Tunes tunest; Iran natunest ("Tunisia could; Iran could not"). As for Bahrain, the Islamic Republic could only watch and denounce as a Sunni-dominated government with Saudi support suppressed fellow Shiites. Bashar al-Assad's regime in Syria, one of Iran's few reliable friends in the region, is engulfed in a burgeoning civil war.

A frustrated Iran is one that will lash out in all directions -- at Israel, at the United States, at Britain (as in the recent attack on its embassy in Tehran), and at Saudi Arabia (as in the alleged plot to assassinate the Saudi ambassador to the United States with the help of Mexican drug cartels). Nonetheless, U.S. negotiators should be careful not to overreact to every claim, every statement, and every bit of bluster coming from the harried leaders in Tehran. Iran would like Washington to dance to its tune, and it likes to show its power by provoking America into unwise reactions. In such cases, language matters, and U.S. diplomats should be measured, clear, and cautious. Let the other side rant and rave.


If these future talks -- or any talks -- deal only with Iran's nuclear program, they will fail. For better or worse, the nuclear program has become highly symbolic for the Iranian side. Exchanges on the subject have become an exercise in "asymmetric negotiation," in which each side is talking about a different subject to a different audience for a different purpose. The failure of such exchanges is certain, with both sides inevitably claiming afterward, "We made proposals, but they were not listening."

For Americans, the concern is technical and legal matters such as the amounts of low- and high-enriched uranium, as well as the type and number of centrifuges in Iran's possession. For Iranians, the negotiations are about their country's place in the world community -- its rights, national honor, and respect. As such, any Iranian negotiator who compromises will immediately face accusations of selling out his country's dignity. Such was the case 60 years ago between Prime Minister Mohammad Mosadegh and the Anglo-Iranian Oil Company when the British insisted on the sanctity of contracts and the Iranians sought to rectify a relationship out of balance for over a century. Today, the United States risks falling into the same trap of mutual incomprehension.

President Mahmoud Ahmadinejad's words on the subject are revealing. He says, "We do not believe in making atomic bombs. We believe that goes against human morality." He adds, however, that the decision to build or not build such a weapon is Iran's decision to make. No one else -- not the United States, the United Nations, the IAEA, or the European Union -- can tell Iran what to do. It is Iran's right to make that decision. In other words, "Others are seeking to impose their will on us; we are seeking to assert our national rights."


So if not nukes, what should the talks be about? If U.S. negotiators are interested in going beyond the most difficult issue on the table -- Iran's nuclear program -- and exploring areas where "yes" is possible, they need to be talking about Afghanistan, Iran, terrorism, drugs, piracy, and other areas where, in a rational world, there exists basis for agreement. Such will never happen, however, if U.S. and Iranian officials cannot talk to each other.

Before the United States enters another round of talks, it must make certain that the Iranians will not re-enact the farce of their January 2011 meeting with the P5+1 in Istanbul. At that session, Iranian representative Saeed Jalili, apparently under instructions from Tehran, deliberately avoided a bilateral meeting with U.S. Deputy Secretary of State William Burns. The sad irony is that, among senior U.S. officials, Burns is probably the only one prepared to listen seriously to Iranian concerns. In fact, the two had met productively in Geneva in 2009 to discuss a deal to supply fuel to Tehran's research reactor. If the Iranians won't talk to Burns, however, then there is no one in Washington who will listen to them. Of course there is little one can do if the Iranians insist on rubbing salt into self-inflicted wounds. But they should know the opportunity is there.

Although the Geneva deal eventually collapsed, those 2009 talks are still the only high-level meeting between U.S. and Iranian officials during Barack Obama's presidency. Iranians and Americans need to be talking again at that level, and about much more than just their nuclear programs. In the preparations for the next round of talks, the Americans -- through the designated P5+1 channel -- should make two points:

1. Burns looks forward to a bilateral meeting with his Iranian counterpart.

2. He is prepared to listen to Iranian concerns on all issues and explore areas of potential agreement and further discussion.


The United States should be wary of overplaying its hand -- something it often accuses the Iranians of doing. It should be realistic about the effectiveness of so-called "punishing" and "biting" sanctions. Just who gets punished and bitten by these measures? Such actions may have their effects, though perhaps not on those in Tehran whom America is seeking to influence. If Iran cannot sell crude oil, it will clearly be in serious trouble. But if sanctions do not bring the Iranians to yield -- and 32 years of sanctions have not done so -- the only way to do so may be long-term measures to lower the world oil price so that Iran faces an economic crisis it cannot avoid no matter how much oil it sells.

Nor should the United States oversell the "threat" from Iran. The Islamic Republic, through its economic mismanagement, inept diplomacy, and talent for making gratuitous enemies, is chiefly a threat to itself. Although the prospect of a nuclear-armed Iran is very worrying to others in the region, it is difficult to see how a nuclear weapon serves Iran's interests or helps the current authorities stay in power. A nuclear weapon is of no use against urban demonstrators seeking a government that treats them decently or against restive ethnic minorities seeking cultural rights and a fair share of political and economic power.

The chief threat to the Islamic Republic, in the government's own words, is not an invasion of foreign armies, but a "soft overthrow," a velvet revolution fueled by hostile foreign countries and local Iranian "seditionists."

Whenever negotiations occur, there will be no quick breakthroughs. If there is any progress, it will be slow, and it will measured in small achievements -- something not said, a handshake, an agreement to meet again, a small change in tone. Above all, what is needed is patience and forbearance. The Americans cannot simply throw up their hands and say, "Well, we tried, but they are just too irrational (or devious, or suspicious). Let's return to what we have always done." One thing is clear: Three decades of demonization and hostility have accomplished nothing. Both sides need to stop shouting and start listening.