Why are so many Muslim women in Europe susceptible to ISIS propaganda? Many of them join ISIS to commit jihad, or violence in the name of the “sustained struggle” to advance Islamic extremism. In 2014, about 18 percent of all European ISIS members were female. As of August 2017, experts believe the total number of women is more than 550. But are women brainwashed by the Islamic State or choosing jihad of their own free will?
Many Muslim women in Europe are enticed by ISIS’s recruitment videos and social media presence. ISIS portrays the Caliphate as a utopian land where ISIS’s very narrow view of Islam is strictly enforced. ISIS uses Hollywood-level video production and a social media strategy which rivals any Silicon Valley startup. On social media, women members of ISIS promise their women viewers a fulfilling life married to a devout Muslim man in the Caliphate. These women leave discrimination and alienation in Europe to support jihadis in Syria—or to take jihad into their own hands.
But why are ISIS recruitment efforts so effective? Answering this question requires an overview of how Muslim women are excluded from European society. For example, many French people do not consider a Muslim immigrant living in France to be “French, ” regardless of citizenship. A “French” identity includes Western clothing, language fluency, and a desire to assimilate. The French government and mainstream media view national identity narrowly—“traditional” so as not to make white French citizens uncomfortable.
Immigrant Muslim women are marginalized and their religion, way of dressing, and race are always at the forefront of their minds. They are forced to define their “Muslim” identity as incompatible with their “French” identity. Many choose to perceive themselves as “Muslim” rather than “French” in a nation that shows them time and time again that they do not belong. Taub calls this phenomenon “identity choice.”
ISIS uses these cleavages created by the French government to target French Muslim women who want to wear religious coverings and marry a devout Muslim man without being cast as a social pariah. Recruiters appeal to women fascinated by extremism and enamored with escaping France to join the Caliphate. By creating media channels apart from the French mainstream, ISIS can control the slant and message of their posted content to target and lure.
The divergence of media outlets can explain why recruitment videos spread like wildfire.
The fork in the road: ISIS creates a sophisticated rival of mainstream media, which garners attention from the women who embrace this romanticized extremism
However, ISIS’s savvy productions only explain part of the phenomenon.
ISIS’s chosen messenger? Other women.
British women recruiters are master strategists at romanticizing life under ISIS: they catch more flies with honey than they do with vinegar. ISIS women reach out to other women by creating News Frames of the propaganda. Through a process called framing, they shape and interpret the content of ISIS videos and social media posts to win the upper hand in reaching French Muslim women—their target audience.
The most powerful way to frame ISIS propaganda is to create a utopian image of the Caliphate that is consistent with what many Muslim women have already determined to be their ideal society.
Women recruiters can frame ISIS propaganda to convince a woman that joining is in her own best interest. Here’s three ways how:
By glorifying this active role for women, recruits develop an affinity for a Caliphate ready to welcome them with open arms.
Despite its recent territory losses, ISIS still manages to release a few recruitment videos. Nations committed to countering violent extremism cannot fight fire with fire: instead of sensationalizing the videos and perpetrators to the public, European officials and mainstream media outlets must disseminate content that exposes these recruitment tactics that put women at risk.
In addition, French society must broaden their definition of “European” to include Muslim immigrants. In order for this shift in public opinion to occur, European mainstream media needs a new approach: discussing Muslim women as French citizens or residents, not permanent outsiders. Media accomplish this goal by at the News Frames stage of the model above.
Elected officials in Europe must rise to their higher calling as public servants and unite citizens of all religions and national origins under a new “European” identity. Factionalism may be good for getting votes, but this tactic has succeeded at the expense of Muslim women’s livelihoods. This is the most difficult and far-reaching change to implement, as the model suggests.
If France better integrates its immigrant communities, French Muslim women can emerge from the margins of society. ISIS’s power to prey upon these women diminishes when women can practice their religion, wear garments of their choosing, and access education and employment opportunities.
ISIS’s glossy social media images will lose their luster for the many women they once seduced. The news frames won’t be as effective for Muslim women immigrants once Europe stops treating them as “the other.”
Caveat: The opinions expressed in this blog are those of the author. They do not necessarily express the views of either The Institute of Public Diplomacy and Global Communication or The George Washington University.
Just a day after Attorney General Jeff Sessions recused himself from any investigations into the Trump’s campaign contact with Russia, the Institute for Public Diplomacy & Global Communication partnered with the Walter R. Roberts Endowment to host a lecture and Q & A with former ambassador to Russia, Michael McFaul. McFaul’s lecture explored what had ignited the U.S.’ new Cold War with Russia – and what had changed after nearly 30 years of relatively constructive relations. In his lecture, McFaul outlined three possible explanations for the faltering relationship and Russia under Vladimir Putin.
We cannot blame international politics
Firstly, McFaul discussed why the inherent structure of international politics doesn’t account for Putin’s interest in expansion or the strained relationship the U.S. has with Russia now.
“There’s this idea that this is just a natural correction. That Russia is a great power and is acting like a great power,” McFaul said.
But if that were the case, that Putin being more aggressive is just a natural correction, a similar pivot would have happened with Japan and Germany after World War II. At that time, great powers had fallen, but with U.S. aid and investment in each country’s ability to establish a democratic government, each country became a global power without becoming aggressors towards the U.S. If Russia were simply building up to become a major power again after the fall of the Soviet Union, there wouldn’t be a need for a strained relationship between the U.S. and Russia. Instead, perhaps the two countries could have worked together to establish a stronger democracy in Russia. According to McFaul, an error the U.S. made was not investing enough in Russia after the Soviet Union collapsed.
Up until 2013, the world seemed to think that Russia was just becoming a more mature, global power. It wasn’t until Putin’s plans shifted so wholly that the rest of the world started to take notice that Russia was becoming an aggressor, not a peaceful power.
But it wasn’t until 2013 that the rest of the world started seeing a real shift in Putin’s plan. In 2013, Putin was concerned with the Eurasian Economic Union. He wanted the Ukraine to come on board with the EEU, rather than join the West to make the union large enough to be sustainable. Furthermore, up until 2013, Putin seemed to be going in a positive direction on the world stage mostly because of the olympics. The Sochi Olympics was Russia’s time to export a “new Russia” to the rest of the world. Putin’s administration reclaimed authors and artists that were excommunicated during the Soviet Union, and presented Russia as an inclusive country.
“They released Khodorkovsky. [Russia was] essentially saying, ‘We’ve had a rocky space. This is a signal to you, the United States, to have a new relationship with us’,” McFaul said.
Soon after the Olympics’ closing ceremony ended, though, Putin invaded Crimea.
If international politics was the real reason the new Cold War began, it would have started far before Putin decided to invade Crimea because simply the idea of Russia becoming a great power isn’t a threat to the world order or balance of power.
And it’s not U.S. Policy
Another theory McFaul was quick to dismiss is that Russia has to be aggressive towards the United States because U.S. foreign policy pushed it into a corner. But to Putin, the U.S. seemed to be an emerging threat around in the early 2000s and into 2013. NATO’s expansion, the U.S.’ invasion of Iraq, the NATO bombing in Serbia in 2013 and U.S. support for color revolutions all could have been perceived as Western aggression towards Russia. According to this theory, “We are too demanding of Russia, we were lecturing them, we support color revolutions. Putin had enough and his actions are a reaction to what we did”.
However, after these perceived threats the U.S. and Russia began a reset designed to be a win-win relationship between the U.S. and Russia – the idea was that through a strategy of active engagement, the U.S. and Russia would find common interests to strengthen both countries. It is important to note that at the time of the reset, Medvedev was president, and seemed more open to more open relations with the U.S. According to McFaul, this worked for the most part. The new START treaty was put into force in February 2011, and it called for nuclear limits on both countries, eighteen on-site inspections of both countries and no constraints on missile defense or conventional strikes. During the reset, the Iran deal was also signed, which worked in both the U.S. and Russia’s interest to stop Iran from developing a nuclear weapon. Furthermore, the reset also included the Northern Distribution Network (NDN), which supplied material to forces in Afghanistan in a combined effort on the war in Afghanistan.
“At the height of the reset, sixty percent of Russians had a positive view of Americans, and sixty percent of Americans had a positive view of Russians. That was five years ago,” McFaul said.
U.S. policy aided Russia during the reset – and it showed in approval ratings. The economies of both countries were steadily rising and there was more support of American-Russian relations than had been in years. If U.S. policy were to blame, how could one explain all of the positive developments in the relations after the perceived threats? According to McFaul, there is only one last narrative that could explain today’s tensions.
Russian Domestic Politics – it starts at home
When power shifted from Medvedev to Putin, the U.S. incorrectly thought that nothing should really change, according to McFaul.
“We all knew that Putin was doing everything behind the scenes anyway. We didn’t think anything would change,” McFaul said.
However, internal pressures created Putin’s aggressive pivot towards the West because he needed someone to blame the conflict on. Putin saw the U.S. supporting the revolutions in Egypt and Libya – and in his view in Russia too. Putin viewed demonstrators as traitors. Once Putin’s ally and Ukrainian leader Yanukovych fell in 2014, Putin pivoted completely against the U.S. as he saw U.S. ideology threatening his reign. The demonstrations in the Middle East and in Russia between 2011 and 2012 forced Putin to try and look stronger in his own country.
“The good news is, I don’t think Putin has a master plan to recreate the Soviet Union,” McFaul said. “There’s no evidence that that’s what he’s doing. The bad news is that Putin’s not changing. He can be in power legally until 2024, and Putin needs an enemy.”
As long as Putin feels threatened by revolutions and demonstrations in his own country and in those immediately surrounding Russia, the U.S. will continue to be his enemy. And, according to McFaul, a Trump presidency that is friendlier towards Russia won’t do much to change that.
Trump’s hothead meets the Cold War
Trump speaks about Russia as if the goal is to be Russia’s friend, McFaul theorized, and that could backfire.
According to McFaul, President Trump was confusing goals with means. “The job of a diplomat is to represent your country’s interest in another country. Not to be that country’s friend,” McFaul said.
Because of the Trump Administration’s recent controversies, like Sessions’ recent recusal and Russia’s interference in the 2016, Trump will have difficulty making any headway in Russia–U.S. relations. As of now, it might be politically impossible for Trump to grant any significant concessions to Russia without the exchange looking like political favors.
Furthermore, according to McFaul, there’s not much Russia can give us in negotiations.
“They could lift the ban on adoptions, but on bigger things I’m less optimistic. Our overlapping interests are much smaller than they used to be,” McFaul said.
Unfortunately, it looks like the new Cold War won’t be ending any time soon. But according to McFaul, it’s important to realize that a powerful Russia shouldn’t be a fear. Rather, the more pressing need is to reduce the idea that the U.S. is Russia’s enemy, and that they are ours.
Caveat: The views expressed in this blog are the author’s own and do not necessarily reflect those of the Institute for Public Diplomacy and Global Communication or the George Washington University.
Movies are a very impactful and influential tool towards gaining a perspective of a culture, situation, norm, and/or environment, which is why PAOs acknowledge films as a legitimate form of cultural diplomacy. An American watching a movie taking place in Pakistan will notice norms that differ greatly from American culture, as would a Pakistani watching a film taking place in America. And through that simplistic cultural exchange, each viewer would have a better understanding of the other country. As Rhonda Zaharna mentions in her article The Cultural Awakening in Public Diplomacy, culture determines values, and movies represent culture.
So with this emphasis on movies and their impact, it’s hard to determine which film would be considered an all-encompassing “Best” film in the world. Film festivals that take place in Europe such as the Berlin International Film Festival, Cannes Film Festival, and the Venice Film Festival allow movies from all over the world to win the deserving “Best” film, actor, etc. category. The U.S., however, has only one category devoted to international films (Best Foreign Language Film) in their only film award show: The Academy Awards, or “Oscars”. The lack of international focus in film entries is representative of America’s overall lack of international perspective and interest in comparison to Europe’s.
In his article You Talkin’ to Me?, Begleiter states that Americans express an ignorance of the world by being ill informed about international politics and events, while not even caring enough to learn about them. He sees this lack of perspective as a lack of freedom, even though we pride ourselves on being the ‘freest country in the world.’
The U.S.’s nationalism is even represented on the Oscars website by presenting the Best Film, Actor/Actress, and Animated Film awards (all American-directed and starred, in addition to being spoken in English with no subtitles) at the top with large photos of each winner, while presenting every other category in small boxes below. In terms of placement, the Best Foreign Language Film award is given the same amount of importance as the Best Sound Editing award.
In the European film festivals, on the other hand, that is not the case. For this year’s Berlin International Film Festival, the first three most prominent awards were given to people of completely different countries. The film festival also makes a point to award movies on categories such as the Silver Bear Alfred Bauer Prize, a feature film that opens new perspectives. The Golden Bear for Best Film is the most notable award a film can receive, and the Silver Bear Grand Jury Prize is right below that in terms of importance.
From left to right: The Golden Bear for Best Film: Fuocoammare (Italy); Silver Bear Alfred Bauer Prize: Hele Sa Hiwagang Hapis (Philippines/Singapore); Silver Bear Grand Jury Prize: Smrt u Sarajevu/Mort a Sarajevo (France/Bosnia and Herzegovina)
This festival makes a conscious decision to establish the importance of exposing oneself to new perspectives by specifically rewarding movies that make an obvious effort to do so.
In order to overcome our inherent ethnocentric bias, some embassies consciously make an effort to put on events that combine differing cultures. For example, the Embassies of the Czech Republic and the United States of America created a film festival specifically targeting the exchanging of American and Czech cultures by exposing those from Nicosia and Cyprus to American films but directed by Czech director Milos Forman. It was called the Milos Forman Film Festival and through the combined Embassy efforts, the Czechs were able to be exposed to American culture, while still feeling prideful in their own culture since Forman is from the Czech Republic and, and, subconsciously added Czech cultural references within these American films.
Since movies are such an impactful way to develop a better understanding of a culture different than your own, this type of film festival can be organized in the States as well. French, Japanese, Syrian, Hungarian, etc. embassies in the United States can create film festivals that are directed by people of those descent and represent the cultures of those from those foreign countries as well. There can also be an implementation of film festivals that represent American directors who live abroad and create abroad films in order to create a potential incentive or connection for American audiences to attend these film festivals. One example can be creating a film festival that highlights the work of French director Roman Polanski. Even though he was born in Paris, he has made movies in Poland, Britain, France, and the U.S., marking him the epitome of the quintessential international filmmaker. By hosting a Roman Polanski Film Festival in the states with the Polish, French, and British embassies involved, all four countries can experience and appreciate one another’s cultures, while giving American audiences an incentive to come since Polanski has made popular films in the states as well.
Through this cultural program, American audiences will become more informed about the culture that was represented in the movie he or she saw. And by becoming more informed about a culture, it will allow Americans to not only be less ill-informed, but also more inclined to learn more about said foreign country, it’s politics, international relations, and other foreign countries alike. By acknowledging these different cultures and learning that both your culture and another culture can coexist, it will allow you (American readers specifically) to base future decisions on this knowledge that people, places, and things can be different, and that’s okay.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Institute for Public Diplomacy and Global Communication.
In an insightful and entertaining session on March 24th, U.S. Ambassador to the UK Matthew Barzun discussed the importance of engagement and networks in public diplomacy. Ambassador Barzun described how since almost all phones sold nowadays are mobile phones, the term itself has become an oxymoron. Barzun believed that the term public diplomacy was following the same trend line as the importance of public engagement increases.
To illustrate his point, Barzun asked the audience to describe which 130-year old company produced the first digital encyclopedia. The answer was Encarta, which was backed by the world’s most powerful and rich software company Microsoft. Yet this multi-billion dollar company was driven out of business by a ‘kid from Alabama,’ Jimmy Wales, who developed a bottom up model called Wikipedia, ‘the largest knowledge transfer engine in history.’
Barzun then asked the audience to imagine four squares along the following lines:
According to Ambassador Barzun, the magic was not going digital but going network and digital. But one could have very effective combinations of analogue and network such as conference calls. The key Barzun emphasized is to engage. Inside an organization one can be surprised what one can accomplish if rather than task people, one asks people for help. In public events the key is to listen, seeking not so much to be understood as to understand. “Outreach” or “reaching out” is not nearly as effective as engagement, which involves understanding and listening.
“If you listen, people will hear you differently,” he said. “If you repeat the pattern, good stuff happens.”
Answering a question about socio-media analytics, Ambassador Barzun noted that “things can be very precise without being accurate.” Judge the effectiveness of what is happening in the digital world by comparing the same to the analogue or real world. Computer or digital tools can be misused or overused. Twitter can allow an overuse of a broadcasting approach or power point can be overused to bombard audiences with information: “If power corrupts, Power Points corrupt absolutely.”
Ambassador Barzun stated that public diplomacy can build a reservoir of good will. You can fill the reservoir ‘a cup at a time’ or sometimes with a ‘hose’ and refill it when it gets punctured and fill it again. A positive example was President Obama’s dancing the tango in Argentina, which he said demonstrated humility and an interest in the local culture.
Ambassador Barzun closed by describing the image of the hierarchy, which could be described as triangles, with, for example, a Minister of Foreign Affairs at the top of the pyramid, and the circle of influences such as journalists to the wider public, which could be imagined as a cloud encircling the other two. We are living more and more or our lives online but engagement remains paramount. If one approaches challenges in a hierarchy mindset, one will fail just like Encarta.
I just returned from a week in Berlin—a lively city teeming with people. There is a whiff of spring in the air and the outdoor cafes have begun to crowd the sidewalks with the European buzz that Berliners uniquely create.
But along with good cheer is a damp residue from this past year’s revelations by Mr. Snowden that the American government has been eavesdropping on conversations between German officials including listening to the phone of Chancellor Angela Merkel. A post-NSA hangover has left German intellectuals reeling and ordinary citizens confused and angry. Even the biggest supporters of Atlantic relations have found themselves challenged to defend a kind of surveillance and intrusion so antithetical to modern day Germany.
My trip was an opportunity to practice public diplomacy, which involved meeting with national security experts, academics, and a large contingent of students from multiple countries spending a semester in Berlin. It reinforced for me the importance of face-to-face contact and person-to-person dialogue to listen to the point of view of others.
Virtual diplomacy is great; E-exchanges are useful. But nothing beats sitting around a table, handing a physical business card to a new colleague, and chatting at coffee breaks about family and friends. Emotional setbacks in relationships have real consequences and they are best dealt with in human settings as opposed to on line.
The U.S.-German relationship is at a critical inflection point. We need one another to confront the situation in Ukraine and to find common ground so that American-European-Russian relations do not lead all of us down a dangerous path.
In addition to Ukraine, our countries face common challenges around energy, finance, trade and the growing influence of China. We have multinational trade deals at stake, like the Trans-Pacific Partnership, and monetary policies with impact on one another’s fiscal stability. Not to mention climate change, terrorism, and the problems posed by failing states around the globe.
In the end, I think US-German relations can weather the storm. Pragmatism tends to prevail in both countries. A crisis often brings partners closer together, and for us, decades of close relations. But this relationship, like all relationships, takes commitment on both sides and a willingness to meet, talk, debate, discuss and disclose on the public side to deepen diplomacy.
In public diplomacy, words matters. The situation in Ukraine is not only a battle involving troops – it is a battle over language. All sides in the conflict will choose words that reflect their version of events on the ground. Words can have legal meaning, political weight, and public diplomacy implications.
Key words and phrases for public diplomacy watchers following this crisis:
For the United States, the key public diplomacy challenge will be consistency of language to build a strong public case for a “United Ukraine.” US policymakers will need to be careful to stay on message and avoid veering into dubious terrain by either invoking old Cold War language or creating moral equivalency arguments over “self determination”. For example, Chechens want to determine their own future. Some pro-Russian Crimeans want to determine their own future. Ukrainians want to decide their own future.
In the world of 2014, words travel as fast as technology. My best advice for the Administration: Whichever words President Obama uses should set the script for other policymakers to use. If not, conflicts over words will drive the story.
Ukraine will need good public diplomacy from the U.S.
Secretary Kerry is wise to be heading to Ukraine on Tuesday for both formal and symbolic diplomacy to signal to the ordinary citizen in Ukraine that the U.S. respects its territorial sovereignty and its human dignity. These are the moments when visits really matter.
With Russian troops on the move in Crimea, ethnic Russians also need to know that their rights will be protected. This conflict cannot afford to spiral out of control. Leaving aside the human toll that conflict could take, and the wider war this episode might evoke, there are public diplomacy and economic reasons for all actors in this drama to want a peaceful ending.
Crimea is a major tourism spot for Ukrainians, Russians and Western visitors. Even National Geographic has written about the seaside beauty, the vineyards and orchards of this Black Sea resort. Russia just emerged from a tourism boom in Sochi. It shouldn’t risk sending a message to the world that tourists should stay away from Russia and the Black Sea resorts of Ukraine. Moreover, economic issues like oil prices — which would spike as a result of any sanctions against Russia — should motivate all sides to calm down.
In 1782, Catherine the Great’s military general, Prince Grigory Potemkin wrote of Crimea saying “Russia needs its paradise.” But today, times have changed. This is 2014. Russia should not risk it all. Let’s hope public diplomacy and diplomatic talks result in a win-win for everyone.
On April 12, 2013, the U.S. Embassy in Kyiv hosted a day-long conference for Ukrainian women entrepreneurs focusing on business owners of small and medium enterprises. The goal of the event was to promote the importance of Ukrainian women in fostering economic growth, build the confidence of women entrepreneurs to take on leading roles in business and society, provide practical tools for further empowerment, and serve as a platform for networking.
It was less than one year ago when I visited Kyiv as Under Secretary of State for Public Diplomacy and Public Affairs. Today, seeing the unrest, I am reminded of the importance of US-Ukrainian cultural ties. While in Kyiv, I helped launch the construction of the new American Center to build ties between our two nations. Former US Ambassador John Teft and I knocked down a wall as contractors worked to create a convening place to keep Ukrainians and Americans connecting with one another. I also met with bloggers and media, and was the keynote speaker at the Women’s Forum.
I visited school no. 168 in Kyiv where they are providing mainstream education to students with cognitive and physical disabilities. I met with children learning English through a State Department funded program. I was moved to tears at Babyn Yar, the site of a series of massacres carried out by the Nazis during their campaign against the Soviet Union.
As events unfold, let’s focus on the people as well as the politics. There are beautiful cultural sites throughout the country that must be preserved. Artists, journalists, young people, the LGBT community, and women must have their rights and freedoms.
Tara Sonenshine, former Under Secretary of State for Public Diplomacy and Public Affairs, and currently a Distinguished Fellow at George Washington University’s School of Media and Public Affairs will address the United Kingdom’s House of Lords “Select Committee on Soft Power and the UK’s Influence” via videotape on Monday, December 16 at 5:15 p.m. London time (12:15 p.m. Washington time).
The live testimony will take place at the British Embassy in Washington. The evidence session is public and a verbatim transcript will be posted on the British Parliamentary website shortly after the oral evidence session at this link: http://www.parliament.uk/soft-power-and-uks-influence. The Select Committee was formed May 16, 2013 to examine how soft power reflects national interest.
Ms. Sonenshine will be addressing issues related to the use of “soft power,” “hard power” and “smart power” and how public diplomacy is utilized with respect to international policy. Questions will be posed by the Chairman and other members of the Committee who are all Member of the House of Lords.
Ms. Sonenshine has high level experience in both government and the media, having served in the White House, State Department, and as Executive Vice President at the United States Institute of Peace. In earlier years, she was Editorial Producer of ABC News Nightline and a Contributing Editor at Newsweek. At her current position at George Washington University, she writes on a variety of topics related to public diplomacy and international relations.
This is the fifth in a series of posts on life, culture, and politics in the U.S. and E.U. by Robert Entman, who spent 2012 as a Humboldt Research Prize Scholar at Freie Universität in Berlin. Read more posts here.
During our year in three different European countries, my wife or I had occasion to obtain medical care in each. Of course I didn’t do a systematic study but I saw no evidence that the taxpayer-funded and government-administrated European health care systems resembles the nightmare of many Americans’ imagination. From everything I saw, Europeans don’t experience nasty old clinics with long lines of miserable patients endlessly hassled by bureaucrats so they can get access to nameless overworked and under-trained doctors using outdated technology and drugs. Instead the experience of visiting a doctor is much like it is in America, only better and cheaper.
In our experience with routine medical care in Germany, France and Spain, care was competent, wait times and lines were shorter than in the US, and doctors paid close personal attention. For instance, on every visit, doctors left their desks and personally called out the name of the next patient and escorted him or her into the exam room. That’s never happened to us in the US, where clerks or nurses usher you around until the doctor comes into the exam room. It’s not a crucial difference, but it does illustrate the distance between stereotypes and reality.
Here’s one case study: I had a chronic problem that the doctors I’d seen in DC and North Carolina hadn’t been able to help much, so I thought I’d seek a Euro-perspective. Berlin’s Charité Hospital is one of the leading medical research and teaching centers in Germany. By searching on the internet, I found the name of a doctor who specialized in my malady and had given papers at conferences in the US and participated in international research grants—he was obviously plugged into the latest developments in the field. Like so much else, medicine, at least in affluent countries, is globalized.
It happened that this particular G-I specialist was also Chief of the Internal Medicine division. I contacted his office for an appointment and got one within a couple weeks, without needing any referral. Try getting an appointment with the head of Internal Medicine at a major American teaching hospital and see if you get seen, without a referral, within two weeks.
Subsequently, I had two long office visits with him and three multi-hour tests. These yielded useful information that helped control my symptoms a little better. Here’s the key point: At my final visit, I had to ask my doctor’s secretary to please send me a bill. There was no upfront demand for my insurance papers or co-pay as is inevitable in the US. During my total of five visits, nobody had asked me to pay anything, or even raised the issue of billing.
The day after my fifth visit, I was leaving Berlin for Paris. The secretary was saying goodbye and even after telling her I was moving to Paris I had to remind her that I needed to pay. She said they’d figure it out and send a bill to my Paris address.
The total cost of the two doctor visits—with the chief of internal medicine at one of Germany’s leading medical institutions, no less—and three lengthy test procedures was 104 Euros, or about $130. In the US the cost would easily be 10 or 15 times greater.
Finally, the doctor at Charité wrote me a prescription for a particularly expensive drug that I take every day (a PPI if you must know). In the US, I had to make a special appeal to my insurance company to cover this drug and still had to pay a $40/month co-pay. For 90 pills (three months worth) I pay $120, and the insurance company paid about $1000, or $9.33 per pill. In Berlin, the total cost of 98 pills (three months plus one week’s worth)—with no payment by an insurance company—was $135, or $1.38 per pill. In other words this same drug cost nearly seven times more in the US than in Germany.
The cost differential arises because the US is the only affluent country that allows drug companies to charge individual patients whatever they can get away. This functionally results in American consumers and taxpayers subsidizing drug company profits (and, to be sure, drug research) for the entire world. Recognizing the serious market failures in the pharmaceutical industry, most every country regulates drug prices. US policy is one of my pet peeves, and one of many reasons Americans pay so much more for medical care.
Most importantly, US spending doesn’t yield better medical care or—and this is the bottom line—longer life. Below are life expectancies in some of the top countries in lifespan that are most comparable to US in affluence. The US ranks about 33rd among all countries, according to the World Health Organization (2011), tied with Denmark, Chile, Bahrain and Costa Rica at 79 years and just ahead of Cuba, Czech Republic, Colombia and Barbados at 78:
World Bank, 2012
|RANK||COUNTRY||(YEARS)||GDP per capita (equivalent purchasing power)*|
The US spends hugely more as a percentage of GDP on health care:
Beyond paying way more for prescriptions:
These aggregate data don’t deny that in certain respects Americans might be getting their money’s worth. For instance it’s often assumed that US spending enables more advanced medical treatments and higher survival rates for diseases like cancer. However, it turns out to be extremely difficult to compare survival rates while controlling for the many differences among countries’ populations, including their getting cancer in the first place (US ranks seventh in cancer incidence).
There isn’t much empirical basis for assuming that Americans benefit in any way from their higher spending. But there is quite a bit of evidence that the excess spending is the cost of having a political system so uniquely and thoroughly dominated by wealthy organized interests, such as the pharmaceutical and insurance industries, whose lobbies heavily influence public policy agendas, options and decisions. The Rube Goldberg-like Affordable Care Act, though a step in the right (European) direction, reflects above all the less democratic nature of the US political process when compared to the governments of Western Europe.
Americans pay for their inferior democracy thrice over: their health care system costs more yet delivers inferior care and shorter lifespans. The health of democracy reflects and shapes the physical and fiscal health of its citizens.