Asia Unbound

The third debate between Indonesian presidential candidates Joko Widodo, or Jokowi, and Prabowo Subianto, held over the weekend, was supposed to focus on foreign policy and defense policy. At least that was the idea. It made sense that two men who want to be the president of the biggest power in Southeast Asia, and one that has become increasingly assertive on the world stage, would need to offer their views on Jakarta’s foreign policy. No one seems to have told Prabowo and Jokowi that, though. The debate was bland and both presidential candidates seemed lost talking about foreign policy. Though Prabowo has a detailed campaign platform and can talk in depth about his ideas for economic policy—although sometimes sounding like a more bombastic Hugo Chavez when he rails about the economy—the former general offered little but generalities about what his foreign policy would look like. His lack of any specificity, other than talking about how Indonesia needed to protect its territorial integrity (i.e., Papua) and its natural resources and capital, was especially worrying given Prabowo’s tense relations with countries that are important partners of Indonesia like Singapore, Australia, and the United States.  Prabowo is currently on the U.S. visa ban list because of his alleged links to human rights abuses committed on his watch as head of the Indonesian army’s Strategic Reserve Command. Several Southeast Asian diplomats I have spoken with fear a Prabowo presidency immensely. They worry that, while Prabowo has far more international experience than Jokowi, Prabowo will want to dominate ASEAN leaders’ meetings and will have no interest in the consensual style that Southeast Asia meetings follow.  To some extent, shaking up ASEAN’s style would be a good thing, and could only be accomplished by an Indonesian leader. Unfortunately, Prabowo would be unlikely to push ASEAN in the direction the organization needs to go—that of a more forceful organization that uses its power to promote political and economic opening. What’s more, Prabowo’s constant inveighing against Indonesian capital fleeing Indonesia has Singapore worried that, as president, Prabowo might try to muscle the city-state, which is a haven for that capital and has developed an immense private banking industry. Jokowi was no better in the debate, and he comes with his own concerns on foreign policy. The Jakarta mayor, the first presidential candidate to come of age politically after Indonesia’s democratic transition, surely would be better suited to push the country farther toward democracy. But on foreign affairs, Jokowi has minimal experience, other than dealing with some diplomats and foreign investors during his short stint as Jakarta governor. During the debate, Jokowi tried to project confidence that he actually has a better grasp on foreign affairs than people thought, but he said little about issues critical to Indonesian policy such as ASEAN, the role of Indonesia in ASEAN, Indonesia’s relationship with China and the United States, Indonesia’s views on disputed areas of the South China Sea, and other important topics. Instead, Jokowi talked extensively about how Indonesia must do more to protect the rights of Indonesians who migrate to other countries for work, a reasonable topic given the large number of Indonesians who work in Malaysia, Singapore, and the Gulf kingdoms, where many have allegedly been mistreated. (Issues with mistreatment in Malaysia and the Gulf states have become an irritant in Indonesia’s relations with these nations.) Jokowi also talked generally about the importance of diplomacy in Indonesia’s regional relationships, but seemed to have little idea which of these relationships were most important, or how, more specifically, he might handle the country’s currently contentious relationships with Australia and China, two very important countries to Jakarta. Overall, the debate performance was extremely underwhelming. One hopes that a President Jokowi or a President Prabowo, in office, would gain a far greater understanding of foreign policy than either man has shown on the campaign trail.

India’s new government, led by business-oriented Prime Minister Narendra Modi, has emphasized the importance of restoring India’s economic growth to higher rates, along with restoring India’s place in the world as a great trading nation. It will be important for the United States to advance policies responsive to a more open Indian approach on trade and investment matters. I argue, in a new Policy Innovation Memorandum released today, that a good way to begin revitalizing the U.S.-India economic relationship, currently beset with animosities, will be for the United States to support India’s long-pending bid for membership in the Asia-Pacific Economic Cooperation Forum (APEC). The Indian government will present its budget on July 10, at which point the world will have the first opportunity to see specifics on how New Delhi’s new leadership plans to implement its economic goals. The Modi government is likely to present a new budget which clarifies India’s confusing tax laws, and is further likely to raise foreign direct investment caps in several sectors. This would all be excellent news and would go some distance to signaling India’s renewed openness to international trade and investment. As I’ve written elsewhere, a positive signal on trade couldn’t be more needed for U.S.-India economic ties, which have suffered over the past three years due to increasingly difficult market access complaints on both sides. I recommended in Foreign Policy last month that Washington could respond to an open trade door in New Delhi by “injecting a measure of cooperation” into the trade and economic conversation: first, by convening the Trade Policy Forum, in hiatus since 2010; second, by prioritizing negotiations on the bilateral investment treaty already underway; and finally, by championing Indian membership in APEC as a step towards Indian membership in the Trans-Pacific Partnership trade arrangement down the line. My Policy Innovation Memorandum, Bringing India Inside the Asian Trade Tent, delves into the rationale for supporting Indian membership in APEC in much greater detail. Indian membership would have several merits: providing an initiative on which the United States and India can cooperate in an area that has more typically involved acrimony in recent years; but also providing a means through which India’s economic opening could be supported through technical consultation among the network of open Asia-Pacific trading economies. Further, APEC’s technical working groups focus on many of the precise issues troubling the U.S.-India economic relationship and would provide alternate forums for discussion. From my perspective, this would be a helpful way to bring India further into a multilateral grouping with norms the United States shares, a positive development, and would be a good opening to resolve concerns and revitalize ties. India is the world’s third largest economy in terms of purchasing power parity, and one slated to continue growing in size and importance. But U.S.-India trade has not begun to realize its larger potential—just note Vice President Joe Biden’s call for both countries to increase two-way trade five-fold to $500 billion, rather than the present nearly $100 billion level. (For comparison, U.S. trade with India in goods and services was $96.7 billion in 2013, whereas with China the same measure was $616.5 billion). Bringing India inside the Asian trade tent through APEC membership would be a logical and helpful step. To that end, my memorandum provides a specific diplomatic strategy the Obama administration could follow. Follow me on Twitter: @AyresAlyssa

For those who were born in the Chinese countryside in the 1970s, the story of my birth—as my mother used to tell me—is not atypical. When the labor pains began, my mom sent my siblings to the local midwife asking her to come and deliver the baby at home.  Few people then heard of cesarean section (C-section)—the delivery of a baby through one or more incisions in the mother’s belly and uterus. In fact, only about 10 percent of children in China were born through C-section. The story is dramatically different for those who were born two decades later. Indeed, over the past two decades, we have seen C-section deliveries increase by 50 percent worldwide. The highest C-section rate is found in China, where nearly half of all births (47 percent) use this procedure; in some Chinese provinces, the rate is reportedly as high as 70 to 80 percent. According to a Chinese doctor, more than 80 percent of the pregnant women in China could have a natural delivery. Multitudes of factors, many of which are unique to China, have driven the astonishing C-section rate.  Chinese people, for example, like to pick specific days or times for their children to be born. For practical reasons, some young couples may decide to give birth before September 1 (the first day of school) so that their children can go to school a year earlier. Still others may be so superstitious that they prefer even-numbered birth dates for their babies.  Reasoning along this line, we would anticipate a C-section spike closer to Feb. 19, 2015, the beginning of the zodiac Year of Sheep, as children born in that year are considered unlucky. Despite these practical or cultural factors, the rising C-section rate should be viewed more as a byproduct of the transitioning health system in China. The cultural mindset is put into practice largely because of the increasingly easy access to hospital delivery (nearly 100 percent of the babies in China are now delivered in hospitals) and modern medical technology (which has not only made it easier to identify women with high-risk pregnancies, but also improved the safety of surgery and anesthesia).  This systemic change nurtures the perception of mothers-to-be that a single surgical incision is much easier to deal with than hours of labor pain. Other health system changes have also fueled the shift toward C-sections.  Midwives, who cannot perform C-sections, had played an important role in keeping the C-section rate low in China until the 1990s.  By the turn of the century, traditional midwives had been phased out in China’s countryside.  But in even many urban hospitals, many experienced midwives (zhuchanshi) left their profession due to poor pay and high career risk.  As a result, the number of midwives in China is only 1/8 of that of Cambodia and 1/20 of United States. The shortage of experienced midwives to perform natural delivery means that obstetricians sometimes have no choice but to conduct C-sections. This is especially true when would-be mothers insist on having a C-section.  Given the increasing violence against healthcare providers in Chinese hospitals, doctors who want to avoid conflict find it difficult to say no to the requests for a C-section. Also, since C-sections are more profitable than natural birth—hospitals generally have to spend more on natural childbirths, but are only allowed to charge half of the fees of a C-section—unscrupulous hospitals and doctors may take advantage of the information asymmetry between patients and healthcare providers to encourage the use of C-section. In addition, the increasing demand for C-sections has been indirectly fueled by the one child per couple family planning policy. If women are not allowed to have a second baby, they tend to shorten their time horizon and become less worried that their uterus would be harmed by C-section. True, C-sections are generally considered a safe procedure; they can help women at risk for complications with their pregnancy or labor avoid dangerous delivery situations and can save the life of the mothers and/or baby when emergencies occur.  But as with any type of abdominal surgery, C-sections are also associated with risks and complications for both the mother (e.g., infection, hemorrhage or increased blood loss, injury to organs, adhesions, and extended hospital stay/recover time) and the baby (e.g., premature births, breathing problems, and fetal injury). For most pregnancies, cesarean delivery poses greater risk of maternal morbidity and mortality than vaginal births. Indeed, a growing body of research over the past years points to previously unknown public health risks of C-sections. A 2011 study found that C-sections are a barrier to breastfeeding, as the former is associated with delayed skin-to-skin contact between mother and baby, increased formula feeding, and separation of mother and baby. Research also suggests that delivery shapes the establishment of children’s microbiota (the microbe population inhabiting a bodily organ) and subsequently plays a role in child health. Babies born through C-section are less exposed to their mother’s microbiota than those born through vaginal delivery. For example, C-section may inhibit the full growth of bifidobacteria probiotics in a baby’s gut, which could negatively affect her ability to extract nutrition from breast milk. A 2013 article published in Science Translational Medicine suggests that such a dysfunctional microbiome could lead to severe childhood malnutrition and early stunting (the irreversible outcome of chronic malnutrition in early childhood). In China, an estimated 12.7 million children are stunted. Stunted children are more likely to suffer later in life from non-communicable diseases, such as heart and kidney disease, obesity, and diabetes. Research also suggests that by affecting the initial microbiota to which a neonate is exposed, C-section deliveries may lead to modification of the baby’s immune response system, which in turn may make her more susceptible to allergies and asthma later in life, even put her at higher risk of type 1 diabetes (T1D). The high C-section rate in China is indeed paralleled by rising T1D incidence. A recent study found a mean annual increase of 14.2 percent in the incidence of childhood T1D from 1997 to 2011 in Shanghai, which is expected to double from 2016 to 2020. In 2013, a team of scientists also discovered that people with altered gut microbiota are at risk of developing type 2 diabetes. In this sense, C-sections might be considered another important trigger of the looming diabetes epidemic in China. In order to prevent the high C-section rate from translating into another public health crisis, the Chinese government should act now. In the short term, it should launch a nationwide public health education campaign so that the health risks of C-section are widely known in the society. But better informed moms-to-be alone are not going to significantly bring down the C-section rate, unless the government is willing to invest in the training of more experienced midwives, to deepen the healthcare delivery and payment reform, and to completely abandon the notorious one-child policy.