Artillery fires during North Korea's "largest-ever" artillery drill marking the 85th anniversary of the establishment of the Korean People's Army (KPA) on April 25, 2017. Source: KCNA/via Reuters
AS we look back to the year 2017, it’s safe to say that it was one filled with interesting developments and turn of events in the Asia Pacific’s political, social, and economic landscape.
Some 450 people have been arrested in Tehran in the past three days as the biggest protests in the country since 2009 continue
Iranian students protest at the University of Tehran on 30 December (AFP)
Tuesday 2 January 2018
Nine people were killed as fresh unrest hit Iran overnight, state television said on Tuesday, with protesters trying to storm a police station despite attempts to crack down on the biggest demonstrations in years.
The attack on the police station in the town of Qahderijan, in the central province of Isfahan, led to violence that claimed the lives of six protesters, the state broadcaster reported.
A young member of the Revolutionary Guards and a passer-by were also reported dead in towns near the cultural hub of Isfahan city, while TV reports earlier confirmed the death of a policeman in nearby Najafabad, shot dead with a hunting rifle.
'In recent days, enemies of Iran used different tools including cash, weapons, politics and intelligence apparatus to create troubles for the Islamic Republic'
- Iran's Supreme Leader, Ayatollah Ali Khamenei
That brings the estimated death toll to 21 in five days of unrest that represent the biggest challenge to the Islamic government since mass demonstrations took place in 2009.
In his first comments since protests began last week, Iran's supreme leader on Tuesday accused enemies of the Islamic Republic of stirring unrest.
"In recent days, enemies of Iran used different tools including cash, weapons, politics and intelligence apparatus to create troubles for the Islamic Republic," Ayatollah Ali Khamenei was quoted as saying in a post on his official website.
"What can stop the enemy from acting is the spirit of courage, sacrifice and faith of the people," he said, speaking to a gathering of war widows and their families.
Khamenei said he would address the nation about the recent events "when the time is right".
The US ambassador to the United Nations, Nikki Haley, hailed the protests on Tuesday and called for an emergency session of the security council to discuss Iran.
US President Donald Trump, who has been tweeting daily in support of the protesters, said on Tuesday: "The people of Iran are finally acting against the brutal and corrupt Iranian regime... The people have little food, big inflation and no human rights. The U.S. is watching!"
'What the [US] President is doing is taking the focus off the real reasons for the protests, like the foreign adventures and the corruption, and putting it on himself'
- US official
Iranian Foreign Ministry spokesman Bahram Qasemi said that "Instead of wasting his time by publishing offensive tweets to other nations, Trump should focus on internal affairs of America".
A US official who is following developments told Reuters that Trump’s tweets were playing into the government's hands and allowing it to accuse enemies of the Islamic Republic of fomenting the unrest.
"What the President is doing is taking the focus off the real reasons for the protests, like the foreign adventures and the corruption, and putting it on himself," said the US official, who spoke on the condition of anonymity.
Meanwhile, some 450 people have been arrested in Tehran over the past three days, an official told local media on Tuesday.
"Two hundred people were arrested on Saturday, 150 on Sunday and around 100 on Monday," Ali-Asghar Naserbakht, a deputy in the Tehran city governor's office, told the reformist-linked ILNA news agency.
In recent events, enemies of #Iran have allied & used the various means they possess, including money, weapons, politics &intelligence services, to trouble the Islamic Republic. The enemy is always looking for an opportunity & any crevice to infiltrate &strike the Iranian nation.
Protests remain focused on provincial towns and cities, with only small and sporadic protests in Tehran on Monday evening where a heavy police presence was reported.
"We feel the situation in Tehran is more calm than previous days. Already yesterday, it was calmer than before," said Naserbakht.
He added that no request had yet been put to the Revolutionary Guards to intervene in the capital.
"We will not permit insecurity to continue in any way in Tehran. If it continues, officials will take decisions to finish it," said Esmail Kowsari, a deputy commander for a local branch of the Revolutionary Guards, on state television.
The latest violence came despite President Hassan Rouhani's vow that the nation would deal with "rioters and lawbreakers".
Ali Shamkhani, secretary of Iran's Supreme National Security Council, described the unrest as a "proxy war against the Iranian people".
"Hashtags and messages about the situation in Iran come from the United States, Britain and Saudi Arabia," he told local media.
'Seditionist elements'
Turkey on Tuesday said it was "concerned" by the days-long protests that have engulfed neighbouring Iran, warning against any escalation in the unrest.
"Turkey is concerned by news the protests in Iran... are spreading, causing casualties and also the fact that some public buildings were damaged," the foreign ministry said in a statement, adding "common sense should prevail to prevent any escalation".
At the same time, Iran's intelligence ministry released a statement saying "instigators" have been identified "and will be dealt with seriously soon".
Iran's Supreme Leader Ali Khamenei and President Hassan Rouhani (AFP)
The Revolutionary Guards have yet to fully intervene against the protesters, but published photos on Monday of three wanted people and called on the public to report any "seditionist elements".
Rouhani has tried to play down the unrest, which began over economic grievances in second city Mashhad last Thursday, but quickly turned against the state as a whole with chants of "Death to the dictator".
"This is nothing," Rouhani said in a statement on the presidency website.
"Our nation will deal with this minority who chant slogans against the law and people's wishes, and insult the sanctities and values of the revolution."
Pro-government rallies were held across several towns and cities, reflecting continued support among a large section of society.
Reporting restrictions remained tight, but videos on social media continued to show widespread anti-government protests in many areas.
'People have had enough'
Rouhani came to power in 2013 promising to mend the economy and ease social tensions, but high living costs and a 12 percent unemployment rate have left many feeling that progress is too slow.
The young are most affected, with as many as 40 percent out of work according to analysts, and rural areas particularly hard-hit.
"People have had enough, especially the young people. They have nothing to be happy about," said Sarita Mohammadi, a 35-year-old teacher in Tehran.
"The situation is far worse in the provinces. Agriculture has been destroyed. I know many who have left the north of the country to come to Tehran to work," she added.
Rouhani acknowledged there was "no problem bigger than unemployment" in a speech on Sunday, and also vowed a more balanced media and more transparency.
US President Donald Trump, who has repeatedly criticised Tehran over several days of demonstrations, said it was "time for a change" and that Iran's people were "hungry" for freedom.
The European Union on Monday pushed Iran to guarantee the right to protest and separately British Foreign Secretary Boris Johnson said "the UK is watching events in Iran closely".
"We believe that there should be meaningful debate about the legitimate and important issues the protesters are raising and we look to the Iranian authorities to permit this," Johnson said in a statement.
In 2009, authorities ruthlessly put down protests against the re-election of hardliner Mahmoud Ahmadinejad. At least 36 people were killed in 2009, according to an official toll, while the opposition says 72 died.
As much of the world makes amends for social and political injustices of the past, Russia is lionizing its despots, raising statues to the worst of them. Behind this phenomenon is an ultra-nationalist brand of conservatism that seeks to take Russian politics back to the Middle Ages.
ATLANTA – While much of the world is busy dismantling monuments to oppressors, Russians are moving in the opposite direction, erecting statues to medieval warlords who were famous for their despotism. Understanding this revival can shed light on the direction of Russia’s politics.
In October 2016, with the endorsement of Russia’s culture minister, Vladimir Medinsky, the country’s first-ever monument to Ivan the Terrible was unveiled in the city of Orel. A month later, Vladimir Zhirinovsky, the leader of the ultra-nationalist Liberal Democratic Party of Russia, called for Lenin Avenue in Moscow to be renamed Ivan the Terrible Highway. And in July of this year, President Vladimir Putin christened Moscow’s own tribute to the tyrant, declaring, erroneously, that “most likely, Ivan the Terrible never killed anyone, not even his son.”
Most historians agree that Ivan lived up to his name; not only did he kill his son and other relatives, he also ordered the oprichnina, the state-led purges that terrorized Russia from 1565 to 1572. He also presided over Russia’s defeat in the Livonian War, and his misrule contributed to the Time of Troubles and the state’s devastating depopulation.
Joseph Stalin initiated the modern cult of Ivan the Terrible. But, since the mid-2000s, Russia’s Eurasia Party – a political movement led by the pro-fascist mystic Alexander Dugin – has moved to position Ivan as the best incarnation of an “authentic” Russian tradition: authoritarian monarchy.
Dugin’s brand of “Eurasianism” advocates the embrace of a “new Middle Ages,” where what little remains of Russian democracy is replaced by an absolute autocrat. In Dugin’s ideal future, a medieval social order would return, the empire would be restored, and the Orthodox church would assume control over culture and education.
Eurasianism, which was marginal in the 1990s, has gained considerable popularity in recent years by contributing to the formation of the so-called Izborsky Club, which unites the Russian far right. On several occasions, Putin has referred to Eurasianism as an important part of Russian ideology; he has even invoked it as a founding principle of the “Eurasian Economic Union,” a burgeoning trade area of former Soviet states.
Eurasianism has given ultra-nationalist groups common ground around which to unite. It has also given symbols of totalitarianism, like Ivan the Terrible and Stalin, new legions of support.
Chief among them are members of the Eurasia Party, who consider political terror the most effective tool of governance and call for a “new oprichnina” – a staunchly anti-Western Eurasian conservative revolution. According to Mikhail Yuriev, a member of the political council of the Eurasia Party and author of the utopian novel The Third Empire, the oprichniks should be the only political class, and they should rule by fear.
Ivan the Terrible is not the only medieval vestige being revived in Russia. Cultural vocabulary is also reverting. For example, the word kholop, which means “serf,” is returning to the vernacular, a linguistic devolution that parallels a troubling rise in Russia’s modern slavery. Data from the Global Slavery Index show that more than one million Russians are currently enslaved in the construction industry, the military, agriculture, and the sex trade. Moreover, serf “owners” are also happily identifying themselves as modern-day barins.
Even Russian officials speak approvingly of modern slavery. Valery Zorkin, who chairs the Constitutional Court, wrote in Rossiyskaya Gazeta, the official government newspaper, that serfdom has long been a “social glue” for Russia. And another medieval term – lydi gosudarevy, which translates to “servants of his majesty” – has returned to favor among high-ranking bureaucrats.
Nostalgia for serfdom compliments the desire for a return to autocracy. Prominent Russian intellectuals – including the filmmaker Nikita Mikhalkov, journalist Maksim Sokolov, and Vsevolod Chaplin, a Russian Orthodox cleric – call for the coronation of Putin, and petitions of support are gaining signatures online. Significantly, the protests against Putin’s regime in 2012 have since been interpreted not as a protest against Putin himself, but rather against the social order to which Eurasianism aspires.
Putin’s tacit support for the Eurasian vision of a neo-medieval Russia invokes the historical memory of Stalinism. According to Dugin, “Stalin created the Soviet Empire,” and, like Ivan the Terrible, expresses “the spirit of the Soviet society and the Soviet people.” No wonder, then, that monuments to Stalin, too, are multiplying in Russian cities.
Neo-medievalism is rooted in nostalgia for a social order based on inequality, caste, and clan, enforced by terror. The lionization of historical despots reflects the contemporary embrace of such pre-modern, radically anti-democratic and unjust values. For Ivan’s contemporary champions, the past is prologue.
Dina Khapaeva is Professor of Russian at the Georgia Institute of Technology’s School of Modern Languages. Her most recent book is The Celebration of Death in Contemporary Culture.
(Evan Vucci/Associated Press) By Greg SargentJanuary 2 at 10:10 AM
As we head into 2018, one big, looming unknown is this: Just how far will congressional Republicans go to prevent a full accounting of Russia’s interference in our election and any possible Trump campaign conspiracy with it?
Post media critic Erik Wemple says stoking old scandals is an attempt to sow doubt in Special Counsel Robert Mueller's investigation into President Trump.(Gillian Brockell/The Washington Post)
JANUARY 1, 2018
BERLIN (Reuters) - Chancellor Angela Merkel’s conservatives and Social Democrats (SPD) traded barbs about migration and tax cuts on Tuesday amid mounting questions about whether they can agree to renew the “grand coalition” that ruled Germany for the past four years.
Merkel, under pressure after failing to form a government three months after national elections, hopes to secure a fourth term in office by persuading the center-left SPD to join the government despite punishing losses in September’s election.
Party leaders will meet for preliminary talks on Jan. 3 ahead of exploratory talks scheduled for Jan. 7 through Jan. 12, but a growing number of politicians now say Merkel might have to rule with a minority government, or face new elections.
SPD deputy leader Thorsten Schaefer-Guembel said recent comments by some conservatives were “counterproductive for every form of government formation” and said they had sparked doubts about the will of conservatives to govern together.
He said a deal on a new coalition was far from certain and it was unclear if the talks could develop sufficient trust.
“A minority government remains an option, even if Chancellor Angela Merkel doesn’t want to acknowledge that,” he said in an interview published Tuesday in the Passauer Neue Presse newspaper.
Schaefer-Guembel cited differences with conservatives on a range of issues and rejected as “absurd” proposals by some conservatives to cut taxes for high-income earners.
Conservatives and the SPD are also at odds over healthcare, immigration, Europe, work regulations and pensions.
Schaefer-Guembel said he backed calls by SPD parliamentary leader Andrea Nahles to raise taxes for the wealthiest and urge fresh efforts to prevent big companies from evading taxes.
Acting German Chancellor Angela Merkel address a news conference at the Christian Democratic Union (CDU) party headquarters in Berlin, Germany, December 18, 2017. REUTERS/Hannibal Hanschke
Merkel’s Bavarian sister party, the CSU, has distanced itself from the SPD through policy papers calling for corporate tax cuts, reductions in benefits for asylum seekers, higher military spending and limits on immigration.
The powerful economic council of Merkel’s Christian Democrats (CDU) said it will urge CSU party leaders to push for a minority government when they meet this week, arguing that Germany would face “enormous financial burdens for generations” if the SPD pushed through its spending plans in a coalition.
“A grand coalition will be more expensive in the long term than a minority government,” Wolfgang Steiger, secretary general of the council told the Augsburger Allgemeine newspaper.
The SPD initially wanted to stay in opposition, but agreed to explore the possibility of governing with the conservatives in the interest of political stability after Merkel’s coalition talks with two smaller parties collapsed in November.
Experts say new elections could hand more gains to the far-right Alternative for Germany (AfD) party that entered parliament for the first time in September. Merkel says a new coalition would be more stable than minority government.
Bavarian Interior Minister Joachim Herrmann, a CSU negotiator, told the Funke media group his party would insist on limiting immigration levels. It wanted to extend a temporary ban on family reunifications for migrants who were granted “subsidiary protection”, an asylum status for those not officially classed as refugees.
He said his party viewed it as a democratic responsibility to negotiate a new coalition if policy gaps could be overcome.
“I hope the Social Democrats feel the same sense of responsibility,” he said. “We have an urgent need for action on the legislative front.... We urgently need clear majorities in parliament, we need reliable coalitions.”
A top member of the pro-business Free Democrats, which dropped out of coalition talks with conservatives and Greens in November, said such a coalition remained a future possibility.
Alexander Lambsdorff, deputy leader of the FDP’s parliamentary group, also told the Heilbronner Stimme newspaper that he did not exclude the possibility of new elections or a minority government. “That would not be nice, but it also would not result in a constitutional crisis,” he said.
Maldives depends on tourism and export of fish to sustain its economy. With a majority of the tourists coming from China that would further increase with this agreement and with all the fish exports going to China, it does not need a rocket scientist to conclude that China in due course will have a stranglehold on Maldivian economy.
by Dr. S. Chandrasekharan-
( January 2, 2018, New Delhi, Sri Lanka Guardian) Of the twelve agreements signed with China, during the recent visit of President Yameen to China, the Free trade agreement signed between them is the most important one.
Surprisingly, the agreement that runs into a few hundred pages was passed in an attenuated parliament when the opposition was not present and was over in 30 minutes without any discussion on the merits or the demerits of the agreement.
The present one, is a second such agreement China has with a South Asian country with the other one being Pakistan that has already become a colony of China.
While there was no need for such an agreement with Maldives being able to offer only fish exports that not carry import duty into China, it is China that is going to benefit from this arrangement with all the goods coming into Maldives without any duty. It is just a matter of time before Maldives will be flooded with Chinese goods.
The economics minister of Maldives, who has been negotiating with China behind doors since 2014, justified the agreement that it would be easy to get finance for small businesses and help expansion of financial sector in Maldives. Vague reasons indeed!
On the question whether the Chinese could freely start business in Maldives any time, any where and with any amount, the Minister said that Maldivian laws do not permit such investments. What he did not add and from what we know, the Maldivian laws can be adjusted in any manner with a President who is in full control of the government, the armed forces and the judiciary! Witness the ruling he obtained from the Supreme Court that Parliamentarians would lose their seats if they cross the floor. This was the time (July 13) when several ruling party members joined the opposition with a second no confidence motion being tabled!
Maldives depends on tourism and export of fish to sustain its economy. With a majority of the tourists coming from China that would further increase with this agreement and with all the fish exports going to China, it does not need a rocket scientist to conclude that China in due course will have a stranglehold on Maldivian economy.
The real purpose of China going for such an agreement could be understood from a statement of Global times which it said in criticising India’s stand and I quote- “It won’t be easy for India to maintain its political influence in South Asia if its own economic presence is weakening. If India thinks (that) its position is threatened, it should consider how it can give more benefits to its neighbours through its win-win cooperation.”
This would mean that China’s aim is to have political influence through economic means and it can afford to do so with its deep pockets and aggressive bargaining. Are we to conclude that all the initiatives under the “Belt Road Initiative” are for getting political influence?
But it is still perplexing as to why Maldives has gone for such an agreement that would in due course threaten it sovereignty? With elections coming next year for President ship, Yameen would certainly bid for that post but has to ensure that all credible opposition members are disallowed from contesting. Former President Nasheed is strapped with a fourteen year sentence on terrorism charges and one other possible candidate Gasim Ibrahim who is also not eligible to contest by a constitutional amendment and now in exile after being sentenced to 4 years of imprisonment- the road is now clear for Yameen to have another term. He would need China’s support in international fora if and when he is threatened with sanctions and isolation.
The FTA has been strongly criticised by the opposition in Maldives whose leaders are mostly in exile after being subjected to terrorism charges. Former President Mohamed Nasheed said that Maldives already owes 70 percent of its foreign debt to China and this agreement would leave China to undermine both the foreign policy and sovereignty of Maldives.
For India, it goes against the “India First” Policy” that both countries have assiduously worked for in the last few years. I would go further and say that it goes against the very concept of SAARC with China entering into the region as the “bull in China shop!”
It is said that Delhi was taken by surprise by this agreement. Backdoor talks have being going on between the two countries since 2014 though in secrecy. Yet Male is a very small place and I would be surprised if the Indian intelligence was not aware of it. Certainly the Indian mission there would also be aware of it. The official response that it is all-right if it contributes to the stability of the country!
But India is said to be certainly concerned about the developments. A top delegation from India is expected to visit Maldives very soon to “over come the strained relations” as mentioned in the media in Maldives. There was an editorial recently from “Vaguthu” a mouth piece of President Yameen which said that -I quote “ India is not a best friend but an enemy.” It followed with a direct attack on PM Modi that described the PM as “an extremist Hindu with a history of carrying out extreme actions against Muslims.” The editorial was subsequently removed but the damage has been done.
Former President Gayoom described the editorial as “outrageous.” He said that no Maldivian in his right mind would subscribe to such views. India has been and remains a very close and trusted friend of Maldives”. Former President Nasheed condemned the anti Indian diatribe in foreign policy that is destroying the relationship between the two countries.
China’s intentions are clear. It would like to have political leverage through economic policies as said very openly and blatantly by the Global Times. This is already taking place in Myanmar.
Soon it is going to get too close for comfort for India. It is likely that the new dispensation in Nepal may also go for a free trade agreement with China.
NEW DELHI — In October 2008, Henry Konczak went to get a blood test.
“I was getting short of breath,” says Konczak, a 65-year-old musician and video producer from Ohio. “All of a sudden they said, ‘Get to the hospital immediately.’”
Konczak had a blood infection and spent the next month receiving intravenous antibiotics, but his misfortune didn’t stop there. A doctor discovered that he had a heart murmur and would need surgery to replace his mitral valve. He called the nearby Cleveland Clinic to inquire about costs. The quote? A whopping $130,000, not including the surgeon’s fees.
Konczak says his insurance had been abruptly terminated when he turned 50 and he could not afford a replacement. When he heard the procedure price, he was shocked.
“I said, ‘I’ll send you my financials. I don’t make that kind of money,’” he recalls. “She said, ‘Well, good luck with that.’”
Facing a choice between bankruptcy and death, Konczak chose a third option: India
. On Dec. 23, 2008, Konczak successfully underwent surgery at Indraprastha Apollo Hospital, a prominent private facility in New Delhi. The entire three-week trip — from flights to lodging to medical fees — cost $10,000.
“I saved my life, and I saved my business,” he says.
Konczak’s story may seem unorthodox, but he’s hardly alone. For Americans struggling to meet health care costs, medical tourism has become a surprisingly common choice. Estimating the number of medical tourists is tricky, but according to a government survey, more than 300,000 U.S. residents may go abroad each year for health care. There are many reasons why Americans travel for treatment, but the main one is money.
India is a particularly attractive choice for American patients, since it has a number of hospitals offering quality care from English-speaking professionals at affordable rates. Vinayak Shourie, the international marketing director at Fortis Healthcare, estimated that 20 percent of his company’s business comes from foreigners — and that figure is growing. India introduced medical visas in June 2005 to promote the industry, and it recently began allowing citizens of nearly 150 countries to apply entirely online. The tourism ministry issued more than 170,000 medical visas in 2016, a 45 percent increase over the previous year. It’s become a big business for the country, and business is booming.
But India also has one of the world’s most unequal health care systems. The gap between the services available to the wealthy and the poor is yawning, and roughly 86 percent of the rural population lacks health insurance.
“If you have a lot of money, you can access a lot of medical care,” says George Thomas, an orthopedic surgeon from Chennai, India. “On the other hand, very large numbers of people in India cannot access even basic health care.”
Medical tourism thus presents both opportunities and risks. At its best, the industry can help India grow its health care system, using the revenues generated from international patients to improve local care. At its worst, it risks shifting resources to private hospitals catering to elites at the expense of public institutions serving the poor.
“What’s the effect on health care for Indians? Here, the answer is the story is kind of messy,” says Glenn Cohen, a professor at Harvard Law School and an expert on medical tourism. “But there’s some reason to be concerned.”
***
I am a poster child for the quality of India’s top medical facilities. One month after moving to New Delhi, I started to feel lightheaded and dizzy while walking back from my Hindi class. Shortly after reaching my home, I collapsed, had a seizure, and was rushed by my roommate to the nearest emergency room.
After being discharged, I went to see a neurologist my friend recommended at Max Super Specialty Hospital, a well-regarded private institution. I was admitted for three days and underwent a battery of tests, none of which revealed anything serious. My stay — in a hotel-like private room with free meals and Wi-Fi — was comfortable. My total costs, before insurance, were $2,892.
This was a small fraction of the approximately $25,000 bill I could have been saddled with in the United States. Yet the average annual income in India is only about $1,600, meaning that for many, my medical expenses would have been more than a year’s worth of pay. That stays true if you subtract the roughly $250 extra the hospital charged me as an international patient. Eventually, my health care plan reimbursed me for the majority of my expenses. But most Indians don’t have any medical insurance.
The average Indian hospital, of course, is not nearly as pricey as the top-tier private institutions frequented by wealthy locals and medical tourists. The country’s central and state governments operate hospital networks, and they have enacted various programs to try to ensure that India’s poorer residents don’t have to pay at government facilities.
Public hospitals are overburdened and deficient, frequently producing stories about patients who suffer from medical malpractice
. Recently, a government hospital in Uttar Pradesh — India’s most populous state — made international headlines after 63 people died in two days when the facility ran out of oxygen.
It’s therefore no surprise that Indians prefer private health care. A 2016 government report found that the country’s public facilities treated less than 30 percent of people’s illnesses. The preference is particularly stark in cities, where most of India’s high-quality private hospitals are located. Between 2004 and 2014, the public-to-private distribution of urban hospitalization cases shifted toward the latter by roughly 6 percent. But private health care is more expensive, and during the same period of time, the average amount spent on each urban hospital visit increased by approximately 176 percent.
***
For the industry’s proponents, medical tourism’s promise is this: My experience (and payments) can be channeled, redirected, and perhaps ultimately replicated for India’s less affluent, nonexpat communities. Some, for example, argue that medical tourism inspires Indian doctors to return home — reversing brain drain. Others say it improves services nationwide. Apollo Hospitals executive Preetha Reddy recently wrote that medical tourism helps “contribute to the objective of health for all.”
Josef Woodman, the CEO of Patients Beyond Borders, says the industry is pushing hospitals to seek international accreditation.
“When you get a JCI [Joint Commission International] that comes in and makes certain demands of the hospital, that’s a benchmark for the rest of the health care system,” he says.
But many academics are skeptical that the industry will improve things overall. Valorie Crooks, a health geographer at Simon Fraser University, says medical tourism’s potential spillover benefits were “mostly pie-in-the-sky things” for which there’s little evidence.
Crooks is determinedly nonpartisan in debates about whether medical tourism is, on the whole, good or bad. But she does maintain that any benefits for the local population require well-enforced redistribution.
“Where the benefit can be is in relation to the revenue and ensuring that the revenues that are brought in have some benefit, not just to that private institution but back into the public sector,” she says.
Deepanshu Mohan, a professor at the Jindal School of International Affairs who researches Indian health care, agrees.
“The distribution of the revenue that has accumulated in the private sector has to be worked out,” he says.
Mohan argues that after India’s economy opened up in the early 1990s, the amount of private health care spending shot up while public expenditures languished. The result, he says, is a staggering gap between the nation’s private hospitals and its government facilities.
***
To see what he meant, I visited the All India Institute of Medical Sciences (AIIMS), New Delhi’s most prominent public hospital. Constructed in 1956, the AIIMS campus is a collection of mostly brown, white, and green buildings packed with doctors, nurses, and medical students. Hundreds of patients and their families camp out on the surrounding lawns and walkways, waiting for treatment
. Many have traveled hundreds of miles in hopes of receiving quality, affordable care.
Some are lucky to have reached AIIMS at all. Emergency medical services in India are far more fractured than in the United States or Europe, especially outside cities. Residents of rural regions may not know that ambulance systems exist, and those in need often have to wait long periods and travel substantial distances to find suitable doctors. It’s therefore no surprise that trauma victims in India are more than twice as likely to die as their counterparts in wealthy states.
Among those gathered outside AIIMS is Vishnu Dayal, a 32-year-old farmer who arrived at the hospital two days ago with his mother. She was suffering from bile duct stones — a painful condition that often requires surgery. Dayal had come from Pilibhit, a district roughly 150 miles away.
“Our district hospital is very bad,” he says, explaining why they chose an eight-hour bus ride over receiving local treatment. His criticism is indicative of Indian health care’s structural flaws.
According to the Organisation of Pharmaceutical Producers of India, nearly 80 percent of Indian doctors work in urban areas, serving only 28 percent of the country’s population. Those who do practice outside cities are often dismally unqualified. A World Health Organization report released in 2016 found that only 18.8 percent of people working as doctors in rural India had medical credentials.
Like many of the other patients and attendants sprawled about the site, Dayal was living outside. He spent most of his waking hours sitting on a makeshift mat near the hospital’s central buildings. At 8 p.m., when the AIIMS grounds closed to nonpatients, Dayal packed up, left, and went to sleep on a nearby road.
Despite this, Dayal says he felt santusht (“satisfied”) with his experience. He had good reason. Dayal’s mother had to wait only one day before being admitted, a comparatively short period of time. There are reports of some AIIMS patients waiting months before starting treatment, even when suffering from potentially fatal ailments. Additionally, AIIMS doctors are highly regarded. There was a big gap between AIIMS and the smooth, five-star experience at top private facilities — but an even bigger one between the nation’s flagship public hospital and its desolate rural counterparts.
“It tells you a lot about the quality of medical resources in the area that he is coming from,” Mohan says. “You have a proliferating demand for medical services in cities because there’s a huge amount of migration coming from rural areas.”
Most of these deficiencies are related to low government spending. In 2014, roughly 1.4 percent of India’s public GDP expenditures went to health care, the 15th lowest in the world, and less than half the 3.3 percent of private GDP that was spent. The lack of financing shows. Many government hospitals — especially outside the biggest metropolises — lack critical technology
such as ventilators, leading to needless deaths. Rural regions depend more heavily on government facilities and are therefore especially impacted by the lack of public resources.
This scarcity extends to doctors. The country has only one government physician for every 10,189 residents, and these practitioners work more but are paid less than their counterparts in the private sector. As a result, most doctors try to move into the lucrative private hospitals located in large cities.
Some states are trying to make rural service compulsory for recent graduates of government medical schools. But the idea has received strong pushback from students, and these requirements can be poorly enforced. Physicians serving in public hospitals, for example, are known to open better-paying, time-consuming private practices on the side.
“Without an effective redistribution mechanism … doctors trained within India are more and more likely to migrate from the public health care system to the private health care system,” Mohan says. “The medical tourism industry may lead to an exacerbation.”
The government’s support for the private hospitals that take international patients is also worrying. India’s central government provides financial support to these institutions as part of its Marketing Development Assistance Scheme. Forty-three of New Delhi’s private hospitals received city land at concessional rates. The government made these discounts contingent on each hospital reserving 10 percent of inpatient and 25 percent of outpatient services for low-income individuals, free of cost.
Unfortunately, private hospitals often flout these rules. Last year, New Delhi’s government fined five of the largest institutions roughly $100 million for failing to treat the poor, including Max — the hospital where I received care. It wasn’t the first time the judiciary found that private medical facilities were ignoring state requirements. In 2009, the Delhi High Court fined Indraprastha Apollo Hospital — where Konczak was treated — for violating the terms of its land agreement.
In theory, these penalties may be significant enough to deter future violations (Max Healthcare reported approximately $400 million in gross revenue last year). But Rupa Chanda — an economist and health care expert at the Indian Institute of Management Bangalore — says between judicial delays and corruption, major hospitals could find ways to avoid the full cost.
“The influential will pay their money and get out of it,” she says. “These requirements are not working.”
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An incomplete system that leaves millions of people uninsured. An enormous urban-rural divide. A government that indirectly subsidizes high-quality private facilities that many cannot afford. The more one looks at India’s medical system, the more it starts to look like the American one.
Even the stories of these countries’ underserved populations overlap. Dayal’s mother and Konczak were treated in dramatically different situations. But despite poor health, both spent hours traveling to New Delhi because the hospitals near their homes could or would not provide them with adequate care.
The comparison might be even more apt were it not for the Affordable Care Act (ACA), which extended health insurance to nearly 20 million peoplein the United States. According to experts like Cohen, that’s already leading to a decline in medical tourism, as more people find themselves with adequate coverage at home.
The tax bill that recently passed Congress, however, eliminates the ACA’s individual mandate, and the Congressional Budget Office estimates that the change will increase the number of uninsured Americans by 13 million. Experts say the rising number of uninsured people will, in turn, produce an upsurge in foreign health care travel.
Konczak is a good example of the ACA’s impact. After returning to the United Stats, he eventually managed to purchase “a little bit of insurance” — a $600-a-month major medical plan. Once the ACA was implemented, however, he used Ohio’s marketplace to buy more substantive and affordable insurance that he imagines would have enabled him to do valve replacement surgery much closer to home.
“My health insurance cost monthly went down to $130,” he says. “I almost cried.”
India has no ACA analogue, but its public hospital system was partially designed to provide less affluent residents with affordable and accessible treatment. Like the United States but unlike, say, Belgium or Slovenia, India’s constitution does not list health care as a fundamental right. But it does declare that the government shall regard raising “the standard of living of its people and the improvement of public health as among its primary duties.”
The medical tourism industry highlights these countries’ flaws, and it showcases some of the shortcomings of health care worldwide. Releasing the stress on fractured systems could help ensure a fairer distribution of resources. But it’s hard to see how moving patients to India’s overburdened system makes global health care any more just.
Issues of fairness weighed on Konczak during his trip. It’s nearly impossible to visit India without witnessing stark poverty, and even as he was lying in the ICU, Konczak says he was perturbed by what he saw.
But he didn’t go to India to save the world. He went to save his life.
By 
Iran's Supreme Leader Ali Khamenei and President Hassan Rouhani (AFP)
JANUARY 1, 2018
Indian doctors inspect an x-ray photograph at the Ahmedabad Civil Hospital on March 12, 2013. (Sam Panthaky/AFP/Getty Images) 
BY DANIEL BLOCK- 
