September 22, 2019

By Gerhard Ottehenning

Washington, D.C. — Despite the constant hum of palace intrigue coming from 1600 Pennsylvania Ave., kitchen table issues like health care remain at the forefront of voters’ minds. Riding off the success of the 2018 congressional midterms, Democrats have rallied behind the idea of “Medicare for all” or “single-payer” health care to bring the United States’ system up to par with the rest of the industrialized world. But what kind of health care system does the “rest of the industrialized world” have? 

The common rhetoric in health care debates in the U.S. today can sometimes deliver the impression that there are only two options: whatever it is that we currently have, and “socialized medicine,” with voters attaching various meanings to the word “socialized.” Examination of other countries’ health care systems yields a fuller picture of the various avenues to universal health care. Here at SAIS, international students can provide a unique perspective into the strengths and weaknesses of three such health care systems in the United Kingdom, Germany, and Switzerland.

The United Kingdom’s nationalized, single-payer system provides healthcare for all, but at a cost

The United Kingdom administers health care through the National Health Service (NHS). The NHS is a national, government-run, or single-payer, system. The government provides health insurance, employs health care workers and runs the country’s hospitals. Health care in the UK provides preventative services, mental health services and medical drugs for free, once citizens have paid taxes. Private insurers and private doctors exist for those willing to pay more for supplemental plans. 

Downsides of the NHS include the unavailability of certain drugs, increasing health disparities between the rich and poor, and longer wait times than those experienced by most Americans. Miranda Bain, a second year SAIS student and UK national described some of the challenges she faced under the NHS: “The issue I had was that, because it’s very under-resourced—you only get 10 minutes with a doctor—it can be quite rushed if you’re trying to talk through something complicated and they’re seeing so many people at one time. It was a bit chaotic trying to get to the bottom of what was making me sick.” 

Despite these downsides, Bain said that “people feel very strongly about the NHS and are quite proud of it. Although the current government has made moves to privatize it, if there was a big attempt to do that there would be a lot of protests and grievances from the public.” A comparison of health care systems by the Commonwealth Fund’s International Country Comparison (CFICC) gives the NHS high marks in terms of access to care, administrative efficiency and equity. 

Germany’s health care model: A mixture of public and private insurance systems

In Germany, health insurance is mandatory for all citizens and is provided primarily through a national public system, with those above a certain income threshold buying private insurance. Public non-profits run half of hospitals, private non-profits run a third, and private for-profits run the rest. Income determines health care premiums, and a tax on employees and employers pays the premiums. The government subsidizes children and those below a certain income threshold.

The German system receives criticism for its fee-for-service system, which penalizes doctors if they provide too much care. Additionally, second-year SAIS student and German national Paulina Koch said that there is public criticism of the two-class system. “If you have private health insurance…it’s easier to get an appointment because those doctors can get more money from a private patient than from a public patient. And that is obviously unfair.” While Germany scores highly on the CFICC’s measures of access to health care, it scores lower on health care outcomes and care process. 

Switzerland’s privatized health care system relies on “individual mandate”

Of these three foreign health care systems, Switzerland’s is the only one that can boast to be younger than the average SAIS student—Switzerland established its current health care system in 1996. The Swiss government obligates every citizen to buy health insurance from a private insurer, ensuring that healthy people stay in the system—which helps keep costs low. The majority of doctors and hospitals are run privately. The government provides financial assistance to low-income residents and regulates insurance companies to ensure access for patients with poor health. In the U.S., the Affordable Care Act (ACA) aimed to expand health coverage through the use of subsidies and regulation, similar to the Swiss system; Paul Krugman called the ACA an attempt to “swissify” the American health care system. 

Sarah Aver, a Tsinghua-SAIS dual-degree student and French national who attended college in Geneva, Switzerland, described the Swiss system as “really efficient. Every time you go to see the doctor, you get a receipt, you pay and then you send it to your insurance. You can do it online and it’s always very efficient.”

The Swiss often cite high costs as a major drawback of their system, a point reiterated by Aver. “There’s always a debate about the price. People think it’s too expensive.” While the Swiss system is more costly than either Germany’s or the UK’s, it is still less of a budget-buster than the United States’ current system. 

As in the U.S., politicians in Switzerland continue to debate the role of government in providing health care. Aver said, “because it’s private companies, some people think that it’s the state’s job to provide health care. It’s a debate but for most people it’s not an issue that it’s privatized.” The CFICC gives Switzerland high marks for health outcomes and equity, though its system is judged to fall short in terms of access and administrative efficiency. 

The leading Democratic presidential candidates all mention universal health care as a top policy priority. Bernie Sanders and Elizabeth Warren support implementing a single-payer system dubbed “Medicare for All” that in part resembles the UK’s NHS, with the government acting as the sole health care insurer. Joe Biden and Pete Buttigieg’s campaign platforms focus on shoring up the existing ACA by adding a public option and creating a more competitive insurance market—most closely aligning with the German system. As the Democratic field narrows, expect the candidates to flesh out their plans as they strive to differentiate themselves from their competition.

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September 16, 2019

By Nikole Ottolia

WASHINGTON, D.C. — Brazilians have protested in the streets, world leaders have offered money, #savetheamazon has trended for weeks and yet the fires continue to burn and the debate rages on. Who is responsible for the Amazon Rainforest? Lost between the drama and the hashtags lies the story of how the Amazon came to this point. How did the “lungs of the earth” become a tinderbox of political appeasement and economic ambition?

In his memoir, former Brazilian President Fernando Henrique Cardoso (2006) explained the origins of one of Brazil’s most controversial barriers to development: the distribution of land.

“By 1580, a mere 50,000 settlers had trickled into Brazil. Meanwhile, Portugal’s rival, Spain, was making quick headway in colonizing other parts of Latin America…Desperate to halt the invaders, the Portuguese Crown decided to make colonization of Brazil its top priority. To populate the wild and hostile lands as quickly as possible, the Crown granted unthinkably large tracts of land to a very tiny group of settlers…As technology improved over the centuries, allowing the cultivation of cash crops, such as coffee and sugar, many of these same vast landholdings then became fabulously wealthy fazendas, or plantations, that were—and to some extent, still are—the backbone of Brazil’s economy. That hurried decision by the Crown in 1580 was fundamental to so many of the problems that would later haunt Brazil: slavery, economic underdevelopment, and disrespect for the rule of law…” (p. 209)

Cardoso was referring to deeply entrenched power dynamics that continue in present-day Brazil, with power concentrated in the hands of a privileged few. This description rings especially true when considering the history and present circumstances of the Amazon Rainforest. 

During the colonial era, the magnitude and density of the rainforest was enough to keep most invaders at bay. Yet improvements in technology and a growing Brazilian population have increasingly brought the Amazon under threat. While the world may take notice of the destruction of the Amazon today, the forest’s history has always been marked by the suffering of indigenous tribes caught between greed and inconsistent government policies.

In the 19^th century, Brazilian law determined that indigenous peoples’ material and personal rights be placed under the protection of the “Justice of Orphans.” This effectively characterized indigenous peoples as incapable of autonomous interaction with “civilized” society and as a population in need of guidance and protection, much like an orphaned child (Rodriguez, 2002). In 1916, the Brazilian Civil Code included “Indians,” grouped together with minors and the mentally ill, as among those considered “relatively incapable” of exercising their rights. One might think such perceptions of Brazil’s indigenous peoples might have changed in modern times—but as recently as April 2015, Brazilian politician Jair Bolsonaro said of the indigenous peoples, “The Indians do not speak our language, they do not have money, they do not have culture. They are native peoples. How did they manage to get 13% of the national territory?” (Campo Grande News, 2015)

They “managed” this thanks to the decree within the Brazilian Constitution of 1988 that Brazil recognize indigenous people’s “original rights over the lands that they have traditionally occupied, it being the duty of the federal government to demarcate these lands, protect them and ensure that all their properties and assets are respected.” However, the federal government has never completed this demarcation process and indigenous rights remain vulnerable to the mercy of whoever is in power.  

The 1988 Constitution was written as Brazil made a return to democracy following two decades of military rule from 1964 to 1984—a dictatorship that President Jair Bolsonaro describes as a “glorious” time in Brazilian history. Bolsonaro’s rhetoric has been enough to embolden farmers living on the edges of the Amazon Rainforest to claim land that falls within the jurisdiction of indigenous tribes. In her recent testimony to the U.S. Congress, SAIS Professor Monica de Bolle noted, “The rise of deforestation precedes President Bolsonaro’s electoral victory. But the dismantling of environmental agencies under his watch and his past and present rhetoric on environmental issues have emboldened farmers, loggers and other players to engage in predatory behavior in the rainforest.” 

Throughout modern history, the Amazon Rainforest has been a political tinderbox, but it was President Bolsonaro’s voice that sparked increasingly aggressive and illegal encroachment on what should be protected land. To make matters worse, Brazilian society is more politically divided than ever and the country’s economy continues to lag after a recession in 2015 and 2016. With 80% of the country’s population living in coastal areas, the Amazon is “out of sight and out of mind” for most Brazilians who will likely turn their attention back to their everyday lives. 

Now that the world has realized it will choke if the Amazon continues to burn, it may not be easy for Bolsonaro to brush off pressure to improve protection of the Amazon. Yet global attention and discourse on this issue will fail to drive real improvement  if the Brazilian government and its people do not acknowledge the legacy of colonization and indigenous peoples’ rights. Unfortunately, for that to happen, Brazil may have to wait for the next presidential election—but until then, what will become of the Amazon Rainforest? 

Sources: Cardoso, F. H., & Winter, B. (2006). The accidental president of Brazil: A memoir. New York: PublicAffairs, 209-210. 


Constitution of Brazil. (1988). Available at: https://www.refworld.org/docid/4c4820bf2.html  


De Bolle, Monica. (2019). Preserving the Amazon: A Shared Moral Imperative. Peterson Institute for International Economics. Retrieved from https://www.piie.com/commentary/testimonies/preserving-amazon-shared-moral-imperative


Marques, A. & Rocha, L. (2019). Bolsonaro diz que OAB só defende bandido e reserva indígena é um crime. Campo Grande News. Retrieved from https://www.campograndenews.com.br/politica/bolsonaro-diz-que-oab-so-defende-bandido-e-reserva-indigena-e-um-crime


Rodrigues, M. (2002). Indigenous Rights in Democratic Brazil. Human Rights Quarterly, 24(2), 487-512. Retrieved from http://www.jstor.org/stable/20069611

By Sydney Tucker

NANJING, China — Historically, China has been a nation filled with propaganda. On almost every city block, one can find the 12 guiding principles of Chinese socialism, including freedom, equality, democracy, harmony and patriotism, plastered on a wall. These core values remind Chinese citizens of the foundational building blocks that guide their country, though many of these ideals have yet to actually manifest in Chinese society. From billboards to subway ads, signs feature one-liners promoting socialist values. This method of promoting propaganda is considered traditional, harkening back to the Mao era when Party policy was painted or posted on walls for public consumption. But earlier this year, political propaganda reached new technological heights under the leadership of President Xi Jinping. 

A list of the twelve guiding principles of Chinese socialism. From top to bottom, left to right, “Prosperity, Freedom, Patriotism, Democracy, Equality, Dedication, Civility, Justice, Honesty, Harmony, Rule of Law, Friendliness.” 

In January 2019, China’s Publicity Department launched the country’s first official government mobile app, Xuexi Qiangguo (学习强国), which roughly translates to “studying strengthens the nation.” Intended to help Communist Party members and average citizens gain a deeper understanding of China’s political goals, the app aims to demonstrate the path that Xi wants China’s future development to take. 

Through the app, party members are encouraged to immerse themselves in Xi Jinping thought. According to the New York Times, “Xi Jinping thought” focuses on strengthening China’s three core bases: the nation, the Chinese Communist Party (CCP) and Xi himself. The emphasis on the Communist Party has proven to be the most important. Xi frequently emphasizes that the party is responsible for China’s successes, but not for its problems. Xi’s plan is to take steps he believes will allow the country to become not only an economic heavyweight, but a well-respected political power as well. As China continues to grow and strengthen, the central government wishes to see all of its citizens united under the same political ideology. The Chinese government believes that the single-party system is the driving force for the country’s path to global superiority and hopes the app will promote this belief.

At its core, the sometimes game-like app is designed to award points to users for engaging in pro-China propaganda. Upon registering for the app, users must enter their telephone number, full name and place of employment, and agree to its terms of use. Completing this step earns the user a tenth of a point. Thirty-eight channels are available to “enhance” the learning experience, covering topics such as politics, news, party history, law, new political thought and the ideologies of current and previous Chinese leaders, as well as less political topics including science, technology and traditional Chinese culture. Despite the variety of its content, the app heavily emphasizes politics and reinforces traditional study methods such as extensive reading and rote memorization. The app also includes forms of audiovisual learning through documentaries, news broadcast clips and online courses.

Under the point system, users’ efforts don’t go unrewarded. Wishing to remain unnamed, a Hopkins-Nanjing Center (HNC) professor detailed the ways in which a user can earn points. Tasks including reading,commenting on an article, watching a video or completing a quiz each earn a user one point. Users can even view the scores of their friends, fellow party members, classmates and coworkers to compete for the week’s high score. A running joke among Nanjing University students claims that the higher one’s score, the better spouse or partner one can be. 

Xuexi Qiangguo has quickly risen to the top of app store charts, with over 100 million downloads within four months of its launch date. Notably, downloads of the app briefly surpassed those of WeChat, China’s most popular messaging, social media and mobile payment app, rendering Xuexi Qiangguo the most downloaded app in China’s Apple store.

However, these numbers do not clarify whether the Chinese citizenry are genuinely interested in learning Xi Jinping thought—or if they feel they must do so in order to demonstrate party loyalty.

Culturally, Xuexi Qiangguo is something China has never seen before as perhaps the only app to have made the unprecedented jump out of pop culture and into politics. The Chinese government has harnessed China’s increasing technological sophistication and growing population of Internet users to spread its political influence. So far, the greatest influence has been on younger generations, especially college students.

A CCP-affiliated student at the HNC, who chose to remain anonymous due to the sensitivity of the subject, described the app as “politics made fun,” and believes the app will have a larger impact on students as a whole than the current and well-established method of political indoctrination—mandatory classes on Marxist theory for every undergraduate student. They added that “when I attend my Marxist class, I often focus on everything else but what the teacher is saying. Whether shopping online via Taobao or working on an assignment for another class, I am not emotionally invested in this class because it is required of all Chinese students.” The student believes this app is a creative and effective way to promote understanding of the Party’s political goals.

While competition among friends and colleagues to earn points within the app may be just for fun, users of Weibo, a popular Chinese app similar to Twitter, have expressed concern. Many claim the app intensifies political pressure on party members to prove their political loyalties in a quantifiable way by measuring users’ interest in Xi Jinping thought and the CCP. The HNC student interviewed for comment recalls how a teacher questioned students about news published on the app that very morning, impressed with those who could respond and disappointed in the ones who could not. Similarly, a hospital employee posted online about having to report her score at her workplace on a weekly basis. 

When does voluntary use begin to feel forced? Westerners looking in may view the app as hypocritical, relying on fear of political reprimand to encourage its use, directly contradicting self-proclaimed Chinese socialist values such as freedom and democracy. Forced political conformity works to characterize Xi as a feared leader, rather than a respected one. 

It is too early to determine the future of Xuexi Qiangguo and its influence within Chinese society. However, it is clear that Xuexi Qiangguo hopes to be the future of China’s propaganda machine and wield influence over how citizens view the government. While the app is spun as a positive step to enhance political unity it is important for observers to err on the side of caution. Importantly, this app has raised several questions of concern for Chinese citizens. Are users expected to fall in line with Xi Jinping thought? What are the consequences if they disagree with these ideals? 

Looking toward the anticipated implementation of China’s social credit score system in coming years, it may be only a matter of time before one’s score on Xuexi Qiangguo or similar apps will directly correlate with his or her social standing. If utilized effectively, the app could be used to bend the thoughts of the next generation toward the Communist Party line. 

By Jesse Adler

September 24, 2019

By Ryan Grace

WASHINGTON, D.C. — Seizing on Tunisians’ lack of faith in traditional political elites, two outsiders beat a field of 24 other candidates to advance to the final round of voting in Tunisia’s presidential elections. Law professor Kais Saied and businessman Nabil Karoui, who is currently in jail on charges of money laundering and tax evasion, led the field in the September 15 election and will run against one another in early October. Their success thus far represents a popular shift in Tunisia, where consensus between Islamists and secularist elites has driven politics since the 2011 Tunisian Revolution.  

In the past eight years, Tunisia has struggled to deliver on the promises of the revolution that ousted dictator Zine El Abidine Ben Ali. According to World Bank data, unemployment in Tunisia hovers around 15% and has been estimated to be near 30% among young college graduates. A lack of jobs, coupled with high inflation and a weak currency, has hampered economic development. The repeated failure of the main political parties to address these problems has nurtured disdain for the establishment. This feeling is reflected in voter turnout, which dropped to 33% in last year’s municipal elections.

This election comes at the tail end of a tumultuous summer punctuated by the death of President Beji Caid Essebsi. His passing in late July caused the timing of the presidential elections to be shifted from November to September, placing them before parliamentary elections. This change may have allowed independent candidates such as Saied to attract more attention, as voters were less inclined to focus on party affiliation due to parliamentary results.

The field of 26 candidates included big names such as current Prime Minister Yousef Chahed of Tahya Tounes and Abdelfattah Mourou of Ennahda. According to Nizar Ben Salah, lead researcher at the Maghreb Economic Forum, “the large number of presidential candidates does not reflect diversity…22 out of 26 candidates share almost the same ideas, messages and initiatives.” Those who were able to differentiate their message found success. 

Nabil Karoui’s rise as a populist alternative has been spurred by his successful use of the private television station he owns, Nessma Tounes, to publicize his anti-poverty charity organization’s work to aid Tunisia’s poor and promote the political message of his political party, Heart of Tunis. His populist messaging and business background have led some to call him the “Tunisian Berlusconi,” a reference to Silvio Berlusconi, the Italian media tycoon and longtime politician. His arrest on money laundering and tax evasion charges (which he claims were purely politically motivated) caused Karoui to be in jail during the election. Despite this, he was still able to capture 15.5% of the vote, a large portion of which came from older Tunisians who saw him as someone who could deliver economic reform.

If Karoui is known for being popular and visible through television and media, Kais Saied might well be described as the opposite. Known for his rigid style of speaking and preference for Modern Standard Arabic rather than the Tunisian dialect, the man nicknamed “Robocop” by his supporters built a campaign centered around humility, youth appeal and conservatism. 

Running a small campaign consisting of door-to-door canvassing and a heavy social media presence, Saied’s appeal seems derived from the perception that he might be an incorruptible “clean slate” for Tunisia. He argues for a drastic shift in the political makeup of Tunisia that would introduce direct democracy and widespread political decentralization. This would lead to greater autonomy in local government, which he claims will empower youth. His willingness to take aim at the broader system in Tunisia appealed greatly to frustrated youth, a demographic where he captured 37% of voters between the age of 18-25, and 18.4% in the overall results.

Saied’s conservatism has prompted some concern from the activist community. He calls for the return of the death penalty, the maintenance of an inheritance law that allots women a fraction of the money that men receive, and the continued criminalization of homosexuality. Despite Saied’s success, many activists remain optimistic about the trajectory of social justice issues in Tunisia. Describing this year’s elections, one activist said, “during the debates, topics that were once taboo were talked about on live TV,” reflecting how mainstream political discourse has expanded to include LGBT and women’s rights. 

To win the presidency, the presidential hopefuls will need more than 50% of the vote in the final round. Since leading the first round, Saied has received the backing of at least five other parties, including the Islamist Ennahda party. His appeal to youth is likely to attract more voters in the upcoming round. In contrast, support for Karoui’s candidacy has not grown significantly, and his base of mostly older Tunisians is not expected to increase much. Saied’s support, coupled with the fact that Karoui is currently in jail, has left Saied as the favorite to win the presidency.

Whether Saied or Karoui ultimately proves victorious in the final round of the election, they may both face additional challenges as political outsiders navigating a political environment that still requires successful presidents to build coalitions with political elites. 

Speaking to the Observer, SAIS alumnus and Tunisia-based journalist for El País Ricard Gonzalez (SAIS ’07) explained that, if he wins, “Saied will be a weak President. He was only able to win about 18% of the vote in the first round, and in the last election [former President] Essebsi won 37%. Also, he does not have a political party and will need to make compromises with political elites.”

The unanticipated rise of outsider candidates like Saied and Karoui bodes for an interesting October as Tunisia holds parliamentary elections. It remains to be seen if the anti-establishment wave will carry over to the legislative elections set for October 6.