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A massacre, health, democracy, and the unity of rights

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Today is the 25th anniversary of the Tiananmen Square massacre. How many hundreds or thousands died at Tiananmen Square, surrounding areas, and other cities in China? It is said we will never know. But I think we can say this: The number of people the Chinese government killed the night of June 3 through June 4, and next few days outside Beijing, may well be far more than whatever estimates you will hear.
Why? When the army fired upon those who stood firm for their rights, it hit not only those brave protesters, but also a movement for greater freedom and democracy. Had this movement not suffered that crippling blow from which it is yet to recover, China might well have gone on a different course. It may have been a course that went beyond carefully easing some restrictions and yes, in many realms allowing greater, even far greater, freedom than in years past.
What might a more democratic China have meant for health?
We can only speculate. But it is an important lesson in the unity of rights, how the brutal suppression of civil and political rights harms the right to health as well. And I hope this perspective will serve as further tribute to those who died 25 years ago and to their ideals, with the hope and belief that in this struggle that still lives on, these ideals will yet be realized.
China’s health gains over the past several decades, as economic development boosted living standards and lifted people from poverty, have been quite impressive. Recent social insurance reforms, from health care to pensions, are in the right direction. But consider….
One of the leading causes of death in China is the horrendous air pollution, causing upwards of 500,000 deaths annually according to these Chinese government – but with outdoor air pollution responsible for 1.2 million deaths in China in 2010 according to the authoritative Lancet global burden of disease study.
What if the Chinese government had reported its air pollution readings earlier (it began doing so only several years ago), or published its own statistics of pollution-related deaths (conservative though they are)? Or scientific findings aside, people with their lived experiences, seeing the growth in pollution, could have sooner taken to the media, the streets – and yes, the ballot box – to demand breathable air.
To be fair, the government is now taking some significant measures to curtail pollution, including carbon intensity targets, cleaner fuel standards, fostering its solar industry to slow greenhouse gas emissions, and new regulations in Beijing.
But would the government have responded earlier with stricter targets and regulations, and with increased possibilities of public pressure that targets be met and regulations respected – including by state-owned and other politically powerful enterprises? How would the balance between economic growth and the environment changed in a more democratic country? Might China have had an earlier emphasis on greener measures that also contribute to economic growth – economic growth in service of health and other human goods and not at all costs? Indeed, might China have become an early leader in sustainable development, establishing a global example to be emulated, rather than an example of unsustainable development?
Would tens, even hundreds, of thousands of lives be saved every year? Notably, one of the student leaders of the Tiananmen protests has himself noted that the environment is among the causalities of the lost opportunity that followed Tiananmen.
People in China are increasingly demonstrating against local environmental harms and concerns, particularly regarding industrial pollution. Several planned factories, including a chemical plant, paper mill, copper processing plant, and lithium battery production factory, have been halted by protests in the past two years. Would such protests have happened earlier, to greater effect, in a more democratic country? What if people had more voice in local development? How, in a more democratic country, would the balance have been altered between polluting corporations closely tied to local governments and the people and their demand for health?
A 2013 poll found that 77% of urban residents in China felt that environmental protection had become more important than economic development. What if the government developed and enforced policies based on such priorities, rather than halt construction of the occasional factory, issue protective regulations that too often fail to be adequately implemented, or require environmental assessments but with a nearly impossibly short 10 day public comment period?
Environmental and development concerns are closely tied to population displacement. To feed China’s rapid economic growth and corresponding demand for electricity, China has sought to harness the potential energy of its mighty rivers through a series of major hydroelectric dam, most famously, Three Gorges. From these mega-projects to the municipal government decisions on economic development projects, many Chinese families are displaced from their homes, their communities. What impact does this social disruption have on their health? Social cohesiveness is, after all, a powerful determinant of health. It can suffer when individuals, families, and communities are uprooted. We know from economic development projects in America’s cities that democracy will hardly prevent all such dislocations. But surely democratic requirements of consultation would mitigate the consequences and extent of some of these projects, while local governments accountable to the people they govern, rather than to political higher-ups, would surely be forced to heed local concerns. (Consider that a proposed series of hydroelectric dams in Brazil under its military dictatorship in 1970s would have displaced tens of thousands of people, while the present government’s plan for generating hydroelectric power in the area would displace 200 people. “Dams in the Amazon: The Rights and Wrongs of Belo Monte,” Economist, May 4, 2013.)
We know all too well from our experiences in the United States that democracy is not a sure bulwark against industry capture of regulators or insufficient safety standards. But might an empowered public have been able to prevent at least some of the safety violations that have led to China’s dangerous mines? Thankfully, the death toll is down significantly compared to a decade ago, when the official toll at coal mines topped 6,000, though still more than 1,000 coal miners died in mine accidents in 2013. Having a free society, with strong and independent unions that can demand workers’ rights, that can monitor mine owners’ adherence to safety standards, could surely have prevented some of the tens of thousands of miner deaths since Tiananmen.
What of access to health care itself? One of the biggest obstacles is the hukou system, the registration system that limits the ability of many rural migrants seeking work in urban areas from getting health care (and education for their children). The system currently limits access to public services of more than 200 million migrant workers. Even proposed reforms, primarily to ease restrictions in smaller cities, will still leave 100 million migrant workers facing restrictions, and that is if all goes according to plan. Would Chinese laborers, much less so many, face such limitations on access to health care in a more democratic China? Or with the power to vote, would the denial of their rights have ended already, or would reforms have been far more thorough?
Official policy is not the only factor that determines access to quality health care. So too does stigma and discrimination in the health sector and society at large. When people with HIV/AIDS face discrimination in health facilities, despite laws and policies to protect their rights, when social stigma and silence persistent around hepatitis, fewer people will access quality health care, to the detriment of their health. While again democracy is no panacea, what if civil society were encouraged rather than constrained, even repressed? China does have a small band of organizations, activists, and lawyers doing their best, often in difficult circumstances, to protect the rights of those who suffer discrimination. But with a freer society, where an independent, robust civil society were encouraged rather than feared, what greater progress might have been possible? Is still possible?
And on top of all this are the unknown numbers of lives shortened, even ended, and health otherwise harmed, through political detentions, forced labor, torture, and capital punishment in the world’s top executioner.
We ought to be cognizant, too, of the health effects of China’s foreign policy. Like other countries of its economic stature, it provides some valuable foreign health development assistance, most prominently doctors in Africa {p. 17). But China’s overall foreign policy is notoriously driven by demand for oil, minerals, and other resources, with the view that how governments act within their own borders is their business, not China’s or the world’s. This is quite contrary to contemporary understandings of human rights.
Democracy and human rights at home is no guarantee of robust defense of democracy and human rights abroad. Witness U.S. support for the regimes of Middle Eastern kingdoms due to geostrategic interests, particularly oil. And the democracies such as Brazil and South Africa have disappointed as would-be global leaders on human rights. But might China’s foreign policy be less expressly blind to human rights, had the value system championed by the protesters 25 years ago prevailed? Might at least some of the worst excesses, support for the most heinous of dictators – for helping the odious regime of North Korea to persist, for the persistently genocidal regime of Sudan – have come to an end? Would China not have sold arms to the Sudanese government, a partner in petroleum, even as the government there perpetuated genocide in Darfur?
The United States attests to the imperfections of democracy, the role that economically powerful actors, entrenched interests, and misinformation can play in skewing democracy and undermining health. Other democracies provide a better model. Had the security forces not embarked on a violent crackdown 25 years ago, just which democratic direction China might have moved in, and how far along it would now be, is a matter of speculation, of that world of what-ifs, a space for dreamers and storytellers.
But it is also a space for all of us. It is the space for solidarity with those who stood – and still stand – for democracy and other democratic rights, other human rights including the right to health. What has not come to pass in China did not come to pass because the government itself took a firm stand against human rights and democracy. But through our speculation we can see what impact people demanding their rights might have had, had China’s government chosen otherwise, swayed by the protesters, a seemingly very real possibility a quarter century ago.
The land of what-if is also a land of what-could-yet-be. An imagined past is also a possible future. So to honor those killed in Tiananmen, and to those who have died in the years since because of that opportunity lost, let us stand in solidarity, and lend our hands, our heads, and our hearts to those who strive for human rights today, in China and around the world.

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The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.

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