Public-Health Campaigns as Outsized Threats to Authoritarian Rule

Are certain forms of popular activism more likely to hasten the fall of dictatorships than others? This question occurred to me after reading a recent Washington Post story describing how one Russian woman, Darya Makarova, has turned her own frustration with the poor health care given to her (now dead) young son into a wider campaign that has caught Moscow’s eye:

Thousands have turned out for her rallies, written letters, signed petitions or joined in Internet forums. Since Maxim’s death in November, she has raised money to reopen a children’s clinic, with an emergency room, in her community. She has shamed the city into buying three new ambulances, with proper equipment. She has launched a nonprofit organization, Health Care for Children, that has national ambitions. Politicians have sought her out. Pavel Astakhov, who holds the newly created title of children’s ombudsman, came from Moscow to see her — and then appointed her his unpaid deputy, giving her more access and clout. Even officials from the sprawling and notoriously indifferent Health Ministry started to pay attention.

I can see why government officials would be nervous about this still-modest and outwardly apolitical campaign. Popular activism around matters of public health and safety seems like it should pose a special challenge to authoritarian regimes, like Russia’s, that stake their right to rule on paternalistic claims about their ability to deliver both social welfare and social protection. Movements organized around failures of public health and safety are threatening to these regimes because they call out the paternalistic state for failing at its own game. Whatever the form of government involved, one of the modern state’s fundamental roles is to protect its citizens from public health threats. Even when they serve this function poorly, most autocrats claim to be trying, and these campaigns reveal that they are not succeeding.

Activist groups organized around failures of public health and safety may also be especially threatening to authoritarian regimes because they have the potential to attract large and very motivated followings that cut across traditional dividing lines of profession, religion, ethnicity, and the like. As Kurt Schock argues in his comparative analysis of nonviolent challenges to authoritarian rule, cross-cutting movements can be more resilient in the face of state repression. Describing Ms. Makarova’s organization, the Post‘s Will Englund writes that, “Middle-class people all over Russia have responded…People who have never done anything political before have joined her cause.” Those last words are ones sure to strike fear into the heart of any autocrat whose political survival depends on a certain degree of popular apathy. Even if these organizations don’t advocate directly for democratization, they might have important second-order effects on the prospects for popular challenges by emboldening citizens, creating new activist networks, and exposing chinks in the regime’s ideological armor.

Last but not least, some of the most plausible solutions to failures of public health and safety have a natural affinity with political democracy. Public health and safety are public goods that generally don’t happen without state intervention. Industry does not effectively police itself. The problem with Russian health care is not the absence of a state agency tasked with managing the system; it’s the state’s failure to perform this management task well. At some point, the public loses trust in the state’s ability to oversee itself or industry and starts to look for ways to hold the overseers accountable for their failures and to influence the selection of their replacements. Independent investigative journalists can also be invaluable watchdogs, so mobilization around these issues can also strengthen demand for the kind of press freedom that most authoritarian regimes are loathe to allow.

I’m not aware of any rigorous empirical analysis on the subject, but all of these considerations make me think that popular activism around matters of public health and safety should be especially unnerving to authoritarian regimes that stake their authority on the production of growth and order. I think the political power of this kind of activism is also evident in China, where officials have used a combination of repression and atonement to try to nip in the bud any mobilization in response to the serious public-health failures that seem to occur routinely there as the country hurtles through industrialization. In 2008, for example, when tainted milk powder sickened hundreds of thousands of Chinese and killed a handful of infants, Premier Wen Jiabao apologized to the nation for the state’s failure to prevent the crisis–and then the government tried the organizer of a support group for victims’ families for “inciting social disorder.”

Whatever its political ramifications, I hope Ms. Makarova’s campaign succeeds at improving health care for ordinary Russians. That said, her story also has me thinking that activism on matters of public health and safety could play an outsized role in the development of the kind of sustained popular uprising that would probably have to emerge for democratization to occur in Russia and China. Even if these kinds of organizations don’t formally lead those movements, they could have strong indirect effects in the creation of new and more resilient activist networks and the normalization of anti-government activity. In the end, these campaigns may hit a strategic “sweet spot:” the regime looks cruel and hypocritical if it squashes or ignores them, but the organizations they produce and values they help to spread scratch directly at the regime’s foundations.

UPDATE (August 15, 2011): Yesterday, the Chinese government responded to fast-growing demonstrations in the port city of Dailan over concerns about the health effects of a chemical plant there by announcing that it would shut the plant down. According to the New York Times (link), the decision to shutter the plant “represents an uncommonly rapid response by the authorities to public anger. Local officials elsewhere in China have typically avoided announcing decisions during demonstrations out of fear that it would only encourage more protests.” There are many plausible explanations for the government’s unusual move, but the concerns described here surely rank among them. You can see photos of the demonstrations here, on Google+.

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  1. One might also note that most mobilization against communist rule in Eastern Europe and Russia in the late 1980s occurred around environmental groups concerned with obvious threats to health. Perhaps there is a connection with your argument here? But if so, there might also be an “elite learning” effect: elites become more nervous of apparently apolitical environmental and health groups than they would otherwise be (by watching the results of mobilization in other contexts), so that over time such activities are less and less effective.

    • That case occurred to me, too, because it’s one I know well. The meltdown at Chernobyl — and the state’s inadequate and untruthful response to it — also played a role in catalyzing activism in the USSR. So I think it’s a great example of how gross public-health failures helped to spur mobilization around more “acceptable” issues that eventually led to wider uprisings. As for the learning aspect, I think there’s no question that the Chinese regime is trying to avoid that fate. What’s striking to me, though, is how the public-health failures keep happening and maybe even keep getting worse (or at least more obvious) in spite of that. It’s a serious collective action problem for them, and I can’t see how they’ll succeed in the long run.

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