In a much discussed post, Ezra Klein produced a series of graphs showing that Americans pay more for office visits, scans and imaging, drugs, and other aspects of health care — often, far more — than is the case in Canada or Western Europe.

There is a simple explanation for why American health care costs so much more than health care in any other country: because we pay so much more for each unit of care. As Halvorson explained, and academics and consultancies have repeatedly confirmed, if you leave everything else the same — the volume of procedures, the days we spend in the hospital, the number of surgeries we need — but plug in the prices Canadians pay, our health-care spending falls by about 50 percent.

In other countries, governments set the rates that will be paid for different treatments and drugs, even when private insurers are doing the actual purchasing. In our country, the government doesn’t set those rates for private insurers, which is why the prices paid by Medicare, as you’ll see on some of these graphs, are much lower than those paid by private insurers. You’ll also notice that the bit showing American prices is separated into blue and yellow: That shows the spread between the average price (the top of the blue) and the 90th percentile (the top of the yellow). Other countries don’t have nearly that much variation, again because their pricing is standard.

Bernard Finel, recalling a series of posts and comment threads from a while back, observes,

James Joyner has argued that in order to reduce health care expenditures we need to make a choice — we can’t have it be better, faster, and cheaper.  Yes, we can.  The reason we can is that the choice isn’t simply between better, faster, and cheaper, it is between better, faster, cheaper, and more profitable.  If you cut profits — for medical insurance providers, for medical malpractice insurance providers, for med-mal attorneys, for doctors, for hospitals, and for drug companies — you can have better, faster, and cheaper.  The problem is that our system is essential optimized for profits — our goal is not to make people healthy but to make people wealthy.

That’s true up to a point, although some of this is simply the Find The Umbrella phenomenon combined with arbitrary itemizing of costs.  (Maybe the scans are $900 because they can bill that much for it while something that they’d otherwise bill more for is capped because the insurance companies won’t reimburse above a certain rate.)

Beyond that, as Dave Schuler points out, there’s no good reason to think OUR government is going to hold down costs in the same way the social democracies have.

I see no reason to believe that even if we went to a single-payer system that the federal government would be willing to lower healthcare prices so that we’re spending what France, Germany, or the Netherlands is. Despite the legislative mandate to do so that’s been around for about ten years they haven’t lowered Medicare reimbursement rates. Every year they postpone that painful choice and, indeed, they’re preparing to do so again.

And, indeed, as Kevin Drum acknowledges, nothing in the bills before Congress will do anything at all to reduce costs.

Monday, Samoa will switch to driving on the left side of the road in order to benefit from cheap used cars from Australia and New Zealand.  This gave Time’s Randy James to explain, “Why Don’t We All Drive on the Same Side of the Road?”  It’s especially odd that two-thirds of the world drives on the right, since most of us are right-handed and driving on the left is not only much more convenient but was the norm for centuries.

Theories differ, but there’s no doubt Napoleon was a major influence. The French have used the right since at least the late 18th century (there’s evidence of a Parisian “keep-right” law dating from 1794). Some say that, before the French Revolution, aristocrats drove their carriages on the left, forcing the peasantry to the right. Amid the upheaval, fearful aristocrats sought to blend in with the proletariat by traveling on the right as well. Regardless of the origin, Napoleon brought right-hand traffic to the nations he conquered, including Russia, Switzerland and Germany. (Hitler, in turn, ordered right-hand traffic in Czechoslovakia and Austria in the 1930s). Nations that escaped right-handed conquest, such as Great Britain, preserved their left-handed tradition.

Nor was the U.S. always a nation of right-hand drivers; earlier in its history, carriage and horse traffic traveled on the left, as it did in England. But by the late 1700s, the theory goes, teamsters driving large wagons pulled by several pairs of horses began prompting a shift to the right. A driver would sit on the rear left horse in order to wield his whip with his right hand; to see opposite traffic clearly, they traveled on the right.

One of the final moves to firmly standardize traffic directions in the U.S. occurred in the 20th century, when Henry Ford decided to mass-produce his cars with controls on the left (one reason, stated in a 1908 catalog: the convenience for passengers exiting directly onto the curb, “especially… if there is a lady to be considered.”) Once these norms were set, many countries eventually adjusted to conform to the right-hand standard, including Canada in the 1920s, Sweden in 1967 and Burma in 1970. The United Kingdom and former colonies such as Australia and India are among the western world’s few remaining holdouts.

One would think that the holdouts would switch to right-hand driving if simply for the ability to market their cars more easily.  But, as the decades-long effort to switch the United States to the near ubiquitous and much simpler Metric system demonstrate, people fight very hard to hang on to cultural norms.

Kevin Drum seconds Alex Massie that a British-style nationalized health system is not a politically feasible option in the United States.  Indeed, even Democrats don’t want that:

[W]ith the exception of a few outliers, the liberal community really, truly doesn’t want a fully government owned and operated healthcare system like the NHS.  We want a government-funded healthcare system like Medicare or most of the world outside of Britain.  And unless I’m mistaken, this isn’t a ruse in any way.  That’s really what most of us want: basic care funded by taxes, with additional care available to anyone who wants to pay for more.  France and Holland, not Britain or Canada.

I do think that’s what most want.  HillaryCare was a single-payer system.  That’s what ObamaCare would be, too, if it were politically viable.  Since it’s not, he’s willing to settle for a “public option,” essentially a government-run insurance program that would “compete” against privately run insurance companies.  And he might have to settle for less than that — a system that expands Medicaid and/or Medicare and patches some holes in the existing system.

For a variety of reasons, the public simply doesn’t seem to understand these distinctions.  First, Canada and the UK are the logical comparison points in that they’re fellow Anglosphere countries and the ones with which we’re most familiar.  Second, those who oppose the reform for various reasons have a strong incentive to elide the differences and capitalize on fears people reasonably have about an NHS-style system.  (To say nothing of the silly fears of the “They’d let Stephen Hawking die!” variety.)

Many of the leaders of the pro-reform side are rather dishonest in their presentation, however. They insist that what’s written in the bill should be the limit of legitimate debate when, as Kevin admits and Obama once did, single-payer is the ultimate goal.   The current “as much as we can get” measure is not only a step in that direction but one that will make it inevitable over time as it kills off the existing system of employer-financed insurance.   So, while it’s dishonest to argue against the proposed legislation as if it were NHS-style “socialized medicine,” it’s perfectly legitimate to treat it as HillaryCare Returns.

An honest debate on this is vital. The current system is on a collision course with collapse because the rate of growth in health costs is unsustainable, especially with so many about to hit the retirement rolls.  And there really are significant problems with our hodgepodge public-private system where those of us not on the government dole are reliant on the vagaries of care by whatever provider our current employer offers.

I’m naturally more skeptical than Kevin of government-run anything.  But I’m prepared to be convinced that a French- or Dutch-style system would be an improvement over the status quo.  But pretending that we can simultaneously cover everyone, cut costs, not ration, and retain the current private system for those who want it isn’t a very effective method of persuasion.

“I just purchased a Routan. I really like it. My friends tell me it’s a Chrysler. I firmly say ‘No!’ to them. I proudly point to my Routan and announce that it’s an American engineered German branded Fiat, manufactured in Canada, using some Japanese parts, by a company that is majority owned by American taxpayers. They stare.” – an AutoBlog reader cited by InstaPundit

I’ve argued in the past that health care outcomes like infant mortality and life expectancies are not really very good measures of a country’s health care services since such outcomes are also a function of variables that are outside the control of health care services. A person who is morbidly obese and refuses to change their behavior irrespective of medical advice is going to have a shorter life span that a person who does not. Then there are other factors like accidental deaths, homicide rates, and so forth that also influence life expectancies, but are pretty much outside the realm of health care. For example, if you fall of your roof and die, what does that have to do with cancer treatments, low infant birth weights, etc. Are accidental deaths and homicide rate distributions uniform across countries? If not, then they could be factors that need to be controlled.

Now at the National Bureau of Economic Research we have this part of their Program Report on Health Economics,

June E. O’Neill and Dave M. O’Neill address the NHI issue by comparing Canada’s publicly funded, single-payer health care system to the multi-payer heavily private U.S. system.[31] They argue that differences between the United States and Canada in infant mortality and life expectancy — the two indicators most commonly used as evidence of better health outcomes in Canada — cannot be attributed to differences in the effectiveness of the two health care systems because they are strongly influenced by differences in cultural and behavioral factors, such as the relatively high U.S. incidence of obesity and of accidents and homicides. Direct measures of the effectiveness of medical care show that five-year relative survival rates for individuals diagnosed with various types of cancer are higher in the United States than in Canada, as are infant survival rates of low-birthweight babies. These successes are consistent with the greater U.S. availability of high level technology, higher rates of screening for cancers, and higher treatment rates of the chronically ill. The need to ration when care is delivered “free” ultimately leads to long waits. The health-income gradient is at least as prominent in Canada as it is in the United States.

In other words, when one looks at specific instances of U.S. vs. Canadian health care outcomes the U.S. does come out ahead. Does that justify the considerably higher costs? I don’t know, but it is something to consider. After all, getting a better outcome in terms of survivability for low birth weight babies might have a rather steep cost curve…or not.

This doesn’t mean that the U.S. system is better or that we don’t have to reform our health care system, we clearly need to. In fact, in reforming it we might have to accept lower survivability rates for both cancer patients and low birth weight babies.

Richard Florida passes along this snippet from The illustrated History of Canada:

American draft dodgers in Canada were far outnumbered by the young Canadians who joined U.S. forces to fight in Vietnam.

This factoid may be in that category Stephen Colbert would call “truthy” and Dan Rather would call “false but true.”

Canada did not participate in the Vietnam War for a variety of reasons.  Still, “about 30,000″ Canadian citizens volunteered to fight with U.S. and other Western forces and 110 of them were killed in action and have their names on the Vietnam Memorial. According to Wikipedia, “Canadian immigration statistics show that 20,000 to 30,000 draft-eligible American men came to Canada as immigrants during the Vietnam era; estimates of the total number of American citizens who moved to Canada due to their opposition to the war range from 50,000 to 125,000.”

Regardless, the fact remains that a huge number of Canadian citizens volunteered to fight in a controversial war and a not insignificant number died there.  They, along with others in the Anglosphere (sorry, Québécois) have long been America’s most stalwart wartime allies, willing to pick up a rifle when others would not.

Will Wilkinson became a Canadian at midnight.  Canadian Press’ Bruce Cheadle reports:

Wilkinson, to use the breezy term used by Citizenship and Immigration Canada, will be “waking up Canadian” on Friday morning as new and controversial changes to the Citizenship Act become law.

“It’s a strange thing to all-of-a-sudden one day gain a citizenship to a new country,” the 36-year-old journalist from Iowa said Thursday as he rode the train to Ottawa.  “It’s exciting to me. I like the idea of just having a bigger community.”

Wilkinson is gaining citizenship by virtue of his Saskatchewan-born father, who moved to the United States in the 1960s and became an American, losing his Canadian passport in the process.   When Bill C-37, an amendment to the Citizenship Act, takes the full force of law Friday, the elder Wilkinson will join thousands of so-called “lost Canadians” who automatically have their citizenship restored.

[...]

A new two-generation rule – which ends the line of citizenship for children born outside Canada to Canadian parents who were also born abroad – was inserted as a sort of quid pro quo in Bill C-37. But critics say that while correctly fixing administrative problems that disenfranchised an untold number of Canadians in the past, the government has elected to “fundamentally change” Canadian citizenship law and disenfranchise an untold number of Canadians of the future.

[...]

Rudyard Griffiths, founder of the Dominion Institute, describes a “growing diaspora of disengaged citizens who live permanently abroad, who aren’t assuming any of the responsibilities and obligations, but enjoy almost all of its rights and privileges.”

Apparently, the rule change was set in motion after some Lebanese-Canadians were given asylum in 2006.

While it may seem odd at first blush that an American-born child of a naturalized American citizen could have dual citizenship in Canada, the United States allows dual citizenship, too.  Plenty of Americans move abroad and take citizenship in other countries without losing their American citizenship for themselves or their children.

Of course, the real question is why the United States and Canada still pretend to be separate countries.  We speak the same language (minus, officially, Quebec), are each other’s largest trading partners, members of NATO, and travel more-or-less freely across the largest international border in the world.

Canadian defense minister Peter MacKay argues that NATO faces an existential crisis in Afghanistan and it’s time for “a frank discussion” about the future of the alliance.

In my New Atlanticist essay, “Canada: Time for ‘Frank Discussion’ About NATO Future,” I challenge his premise while agreeing with his conclusion:

Countries routinely go to war, fail to achieve the objectives they sought, and withdraw without permanent damage to their prestige. The United States, certainly, has done it more than once and appears set to do so again in Iraq. Why should alliances be any different? Clearly, most members of the alliance don’t see failure in Afghanistan as an existential crisis to their own country’s security; why, then, is it an existential crisis for the alliance?

Much more at the link.

AP Photo by Christof Stache.

I’ve posted several items today over at New Atlanticist.

In “Europe Helping Iran Get Nuclear Weapons, I discuss Benjamin Weinthal’s charges in WSJ Europe that European firms and governments, particularly those in Germany and Austria, are actively supporting the regime in Teheran and are at best indifferent to Iran’s nuclear program.

In “Canada’s MacKay Unlikely NATO Secretary General,” I note that while some have touted Canadian defense minister Peter MacKay as Jaap de Hoop Scheffer’s successor as NATO’s secretary general, precedent makes it highly unlikely — and argue that it’s high time to rethink the precedent.

Finally, in “EU and Russia Meet on Energy and Security,” I assess the news that leaders of the European Union and Russia are meeting today for the first time since the gas crisis, more for the purpose of testing the waters than achieving any diplomatic breakthroughs.

From the Toronto Star:

OTTAWA–Canada stood alone before a United Nations human rights council yesterday, the only one among 47 nations to oppose a motion condemning the Israeli military offensive in Gaza.

The vote before the Geneva-based body shows the Stephen Harper government has abandoned a more even-handed approach to the Middle East in favour of unalloyed support of Israel, according to some long-time observers.

Thirty-three countries voted for the strongly worded motion, which called for an investigation into “grave” human rights violations by Israeli forces, while 13 nations, mostly European, abstained.

The United States, regarded as Israel’s greatest ally, is not a member of the council.

Marius Grinius, Canada’s representative on the council, said the language of the motion, which accused Israel of sparking a humanitarian crisis, was “unnecessary, unhelpful and inflammatory.”

He said the text failed to “clearly recognize” that Hamas rocket attacks on Israel triggered the crisis.

Canada’s being an oil-exporting country probably helped them vote their conscience.

This is another confirmation that the United Nations Human Rights Council has become absurd.

Ezra Klein wrote an interesting post Wednesday arguing that extending life through medical intervention is expensive and that tradeoffs and rationing have to be made.  The only question, then, is how much value is placed on that extra unit of health care and who’s making the valuation.

The inverse of the American health care system is the British health care system. Where we are the priciest, they are the cheapest. We refuse to make any explicit decisions, instead denying care based on criteria that makes the denial the fault of the patient rather than the system. You don’t have enough money for the treatment. They make all their decisions explicit, relying on criteria that makes the denial the fault of the system’s judgments. We don’t think that treatment worth the cost. Their system gives patients someone to be angry at. Ours has no connection to value. Their system creates more blame, ours engenders more tragedy.

What’s at issue here is rationing. In 2006, adjusted for purchasing power, the United Kingdom spent $2,760 per person on health care. America spent $6,714. It’s a difference of almost $4,000 per person, spread across the population. That’s $4,000 that can go into wages, or schools, or defense, or luxury, or mortgage-backed securities. And there’s no evidence that Britain’s aggregate outcomes are noticeable worse. But they do say “no” a lot more than we do. Their system refuses to pay high prices for medical technologies and pharmaceuticals that it judges insufficiently effective. They’ve forced themselves to make choice, because they have something we don’t have: A global budget.

I never found time to respond to this but several others have.  Andrew Sullivan has the most poignant retort:

One reason I’m a conservative is the British National Health Service. Until you have lived under socialism, it sounds like a great idea. It isn’t misery – although watching my parents go through the system lately has been nerve-wracking – but there is a basic assumption. The government collective decides everything. You, the individual patient, and you, the individual doctor, are the least of their concerns. I prefer freedom and the market to rationalism and the collective. That’s why I live here.

(It’s also, incidentally, a rejoinder to the hordes who question Sully’s right to call himself a “conservative.”) Steve Bainbridge agrees and wonders why Sully voted for Obama, since he’s much more likely to lead us in the direction of nationalized health care than McCain would have been.   Ron Chusid, meanwhile, agrees in theory with Andrew but adds, “Pragmatically we cannot ignore these differences in spending, especially considering the large number of American who are uninsured or under-insured.”

Noah Pollack, though, questions the premise of similar outcomes in the US and UK.  He cites David Gratzer, who in turn cites a Lancet Oncology study:

* The American five-year survival rate for prostate cancer is 99 percent, the European average is 78 percent, and the Scottish and Welsh rate is close to 71 percent. (English data were incomplete.)

* For the 16 different types of cancer examined in the study, American men have a five-year survival rate of 66 percent, compared with only 47 percent for European men. Among European countries, only Sweden has an overall survival rate for men of more than 60 percent.

* American women have a 63 percent chance of living at least five years after a cancer diagnosis, compared with 56 percent for European women. For women, only five European countries have an overall survival rate of more than 60 percent.

Ironically, Ezra has managed to engender a large cross-blog debate about the comparative merits of the US and UK systems despite his longstanding campaign to establish that as a canard. For example, his recent post THE CANADA/ENGLAND FALLACY correctly notes,

It’s natural to look to England. It’s just not all that useful. We will never have a situation in this country where you are not allowed to purchase your own care on the private market. It won’t happen, it’s not under consideration, and it’s not a plausible outcome of any plans being seriously examined. Conversely, something like France, where the government provides base insurance and the private market offers supplementary products, or Germany, where heavily-regulated non-profits compete with each other to offer coverage, is fairly likely.

While extremely dubious of further nationalizing our system, I agree that a UK-style system is incredibly unlikely to emerge here and we’re much more likely to have a public-private hybrid that simply leans ever more public.   I’m not philosophically opposed to the idea, since health care isn’t a pure market (there’s little elasticity of demand, for one thing) and the current system is incredibly inefficient.  But I do fear disencentivizing research and the provision of cutting edge resources and the general DMV-ization of health care.

UPDATE (Dave Schuler)

I’ve written a lot on this subject over the years but my observations are too long for the comments section and too intrusive to include in the update. I’ve put those observations, along with a substantial bibliography of my old posts on this subject, at The Glittering Eye.

Photo by Flickr user Erik K Veland under Creative Commons license.

The company that’s contracted to provide Clear Card, the TSA’s handy-dandy system for screening out terrorists (or, at least, providing people willing to shell out 150 bucks slightly shorter lines) has managed to lose its customers’ sensitive data and compromise the entire system.

The company that runs the Clear system, which speeds customers through airport screenings, has been prevented from enrolling new customers by the T.S.A. after a security breach affecting some 33,000 customers.

Verified Identity System’s Clear program allows passengers to scan their smart cards at a kiosk for a speedier security screening. T.S.A. spokesperson Ann Davis told CBS an unencrypted computer storing the personal information on the cards went missing from SFO on July 26th.

Davis said VIP is a privately run company that the airport provides with background checks of enrolled customers. Now the company must suspend new enrollments, notify affected customers, and secures computers until they can install encryption.

Current Clear customers will still be able to use their cards while the breach is sorted out.

This isn’t really surprising, considering that the geniuses behind this system didn’t figure out that it would be useful to include a photo ID on the card, something that would have been obvious to the average 5-year-old. This, even though they actually take your picture for no apparent reason.

Then again, coming back from Canada Saturday morning, my wife and I had to go through U.S. Customs on the Canadian side of the border, standing in an inordinately long line.  No worries:  There’s a separate line for those who have submitted themselves for security pre-screening and obtained a card from TSA.  D’oh: But not the Clear card but rather something called “NEXUS” which apparently only works for those going between the U.S. and Canada.

You can’t make this stuff up.

I saw this gigantic “Support Our Troops” poster hanging from a building in downtown Montreal over the weekend:

It’s interesting to see given Canada’s image as less martial than the United States, a reputation presumably earned by their sheltering of our Vietnam draft dodgers. It’s useful to recall that, Mark Steyn notwithstanding, America isn’t alone in sending troops into harm’s way. Indeed, Canadian forces are in Afghanistan taking disproportionately heavy casualties.

Yes, even French Canadians.

We visited La Citadelle in Quebec City, the ceremonial home of the Royal 22^e Régiment, whose second battalion has done two tours in Kandahar and sustained at least ten combat deaths.

UPDATE: A commenter and a correspondent, both with Canadian Forces ties, note that the soldier pictured is not in the CADPAT uniform that Canadian troops have worn for the better part of the decade. Indeed, these appear to be the old NATO-standard woodland camouflage pattern BDUs.

I have seen some young soldiers in cammo patterns that aren’t CADPAT since arriving.  Perhaps, though, they are some sort of cadets.

If you’ve volunteered for service in the U.S. Armed Forces but don’t actually want to go to war, don’t count on hiding in Canada.

The Canadian government’s effort to remove [U.S. Army deserter James Corey] Glass contrasts with the warm reception given to deserters and draft avoiders from the United States during the war in Vietnam. And although the war in Iraq has very little support among Canadians, the situation of Mr. Glass and others who abandoned their military positions provokes a wide range of responses. For American soldiers seeking an escape, Canada is no longer a guaranteed haven.

[...]

During the Vietnam War, the Liberal prime minister, Pierre Elliott Trudeau, welcomed American deserters and draft dodgers, declaring that Canada “should be a refuge from militarism.” Americans who arrived were generally able to obtain legal immigrant status simply by applying at the border, or even after they entered Canada.

[...]

Changes to immigration laws have made it far more difficult for deserters to remain in Canada. Deserters wanting at least temporary legal status must be declared refugees. But refugees in Canada must show that they have, as the government puts it, a “well-founded fear of being persecuted” for religious, racial or political reasons. Alternately, refugees may demonstrate that for them to be returned to their home country would put their lives at risk, or would subject them to torture or “cruel and unusual treatment or punishment.”

The piece notes that the scale is much different, with an estimated 20,000 Americans fleeing to Canada to escape service in Vietnam compared to “no more than 200″ during the present conflict. Another big difference, albeit a related one, is that the former were mostly civilians escaping forced military service during the era of conscription. Every single person subject to fighting in Iraq, by contrast, volunteered for military duty. That’s a huge difference.

Story: Small Wars Journal. Photo: photopia/HiMY SYeD via Kerfuffles and Flourishes

Two articles cited in today’s Small Wars Journal roundup have almost nothing to do with wars, small or otherwise, but are nonetheless interesting in showing the state of flux of some key international institutions.

Steven Erlanger reports on a bold attempt to forge a “Union of the Mediterranean” which would be something of a minor league for the European Union.

Perhaps the grandest new idea of France’s president, Nicolas Sarkozy, looking to give his presidency of the European Union a lasting stamp, is the Union of the Mediterranean. An effort to bind the 17 nations bordering the Mediterranean Sea with the European Union around regional projects, the new union will be inaugurated next week at a Paris summit meeting.

But as with some of Mr. Sarkozy’s other ideas, the execution has been haphazard. The Union of the Mediterranean has created resistance among vital allies, like the Germans and the Spanish, and confusion within his own government. The result may be more show than substance.

Peter Alford reports on the emergence of what would be a radical transformation of the G8.

The largest, most expensive gathering of world leaders under the G8 banner convenes today confronted by an awesome array of problems, from runaway oil prices and scarce food to flaring inflation and global warming, but with little prospect of real breakthroughs on any front. Failure this year could call seriously into question the viability of the Group of Eight industrialised nations, a 33-year-old gathering originally of the top Western powers, struggling now for relevance against huge shifts in the world’s political and economic geography.

That shift will be underlined when the “Plus 5″ developing nations issue for the first time their own communique after meeting the G8 leaders on Wednesday at the Windsor Hotel, the luxurious and now heavily-secured summit site on Lake Toya, in Toyako, near here.

Since the 2005 Gleneagles summit, China, Brazil, India, Mexico and South Africa have met annually as the “G8 plus 5″ with the chief summiteers, the leaders of the US, Japan, Britain, Germany, France, Italy, Canada and Russia. But because of their rising economic power, their huge hunger for energy and food and their critical role in deciding a new climate change regime – or not – after the Kyoto Protocol expires in 2012, the Plus 5 communique will carry as much weight as G8 statements.

The summit situation also gives force to calls from France’s Nicolas Sarkozy and Britain’s Gordon Brown, lately joined by Canadian Prime Minister Stephen Harper, for the eight to be expanded to a G13 with the emerging powers as full partners. This idea is strongly resisted by Washington and Tokyo, the Japanese apparently fearing further dilution of their claims to Asian leadership if China gains a seat.

The addition of Russia, a major regional actor but an economic lightweight, to the group in the 1990s opened a Pandora’s box that may be impossible to close. Certainly, China, Brazil and India have stronger claims to membership in the elite economic club than Russia although, I must confess, what Mexico and South Africa are doing on the list eludes me.

Both of these developments — potential breakthroughs in long emerging trends — point to the continual reshuffling of the world order. Attempting to confine major international institutions to its charter members excludes those who now merit membership and who could contribute the the organization’s goals. Opening the window for new members, however, threatens the interests of existing powers in the institution whose ability to steer policy would be diluted.