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Global health, local health: a paradigm of the failures of globalization

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Benedetto Saraceno


"We need visions of public welfare sufficiently strong, appealing, genuine, full of hope and shareability but not so strong as to become ideologies. Is there a vision of the common welfare which does not become the ideology of the common welfare? ".... This was the ending of the last editorial in Souquaderni (November 2013).
We wonder if the widespread (and abused) notion of "global" is not a paradigmatic example of a vision of public welfare that was born with the founding of the United Nations in the immediate post-war period, full of hope and shareability, only to be transformed over time into an ideology or better into an ideological justification of many aspects of neo-colonialism.
A closer look shows that there is extensive literature demonstrating how global approaches in the development of health policies have systematically failed the objective of being able to respond to the needs of local communities (Thomas et al. 2005). Thomas's writing refers specifically to mental healthcare policies and passes a severe and indisputable judgment on the systematic failure of every global approach in the field of health policies. Most likely the reality is more varied than Thomas thought and the undoubtable failures of global approaches must not, however, obscure some important results. For example, there is no doubt that the issue of global mental health has allowed mental health matters to emerge from the niche of psychiatric illness and integrate with major issues of global health and development. In the same way there is no doubt that the global mental health question has enabled the violated rights issues of persons with mental illnesses and disabilities to emerge and become a subject of discussion and public outcry. Finally, there is no doubt that the issue of global mental health has also allowed the introduction of greater scientific rigour both in the discussion on the prevalence and diffusion of mental illnesses and on the evaluation of the effectiveness of treatments.
However each of these positive aspects reflects many negative angles: in prectice the association between mental health and development remains a politically correct statement that never results in an effective association of integrated mental health interventions and poverty reduction and intervention in social inequalities; even if the rights issue has been able to become part of the great global legal and political debate it is struggling however, to become an integral part of the discourse and practice of psychiatry that remains indifferent or hostile; the culture of "evidence base medicine" has certainly had a positive influence on the culture of the experts on guidelines but has not altered current habits of prescribing medecines characterized either by ignorance or complacency to market pressure; finally, the greater ease in evaluating and producing evidence regarding simple treatments has helped promote only simple treatments (more easily assessed with accuracy) and has gradually caused more complex treatments to be cut out, especially the promotion of operations capable of transforming and innovating the services system. Similar limits and analogous failures are evident even in the more general field of global health. The limits of global discussion are obvious: a psychiatric epistemology as universal as it is fragile in its assumptions, a pervasive presence of the interests of the pharmaceutical industry, a cultural hegemony of organizations and professional lobbyists, a technical and cultural universalism of global agencies (including the World Health Organization) limited to statements of principle or normative indications while struggling to confront the actuality of real countries and especially that of local communities. The moral and technical authority of the United Nations agencies has an undoubted beneficial effect when it indicates the major directions of public health but of course these major directions when actually applied may adopt very different orientations either pushing-towards or moving away-from goals that are truly innovative and able to respond to the needs of local communities.
For example, although one can be pleased with the fact that the last Assembly of the World Health Organization, in may 2013, approved the intelligent and innovative mental health action plan 2013-2020, however, these great directives stop at top level (namely the ministries of health of the countries) but very rarely descend to down level (namely the reality of health services). We find this dramatic limit not only if we analyze the real impact of the World Health Organization in countries but more generally, if we analyze the systematic fracture between the discourse of the United Nations and the reality of the countries associated with it.
Ideas and top-down directives are destined to stay top in the same way that outstanding practices developed locally, i.e. down, struggle to produce an impact on the highest decision-making levels (as is the case of local innovative practices that fail to become national policies). Therefore, alas, also down practices are destined to stay down and not to affect top decision-making processes.
This is not pessimism but a simple observation from which to start reflecting on how to make the top-down and down-top dynamic effective and truly interactive. In fact, if there is a Global rhetoric there is also a Local rhetoric. In the same way there are prophets of both dimensions: perhaps the first, globalists, not foreign to the inferior culture of neoliberalism and wild globalization and the second, localists, not foreign to the risks of community tribalism that easily transforms the need for local democracy into regression, closure to modernity and cultural xenophobia. Therefore it is not a question of accepting neither of the two poles but rather to take on the complexity of the issue in order to avoid the risks of its polarization.
The question could be formulated in an evident but nevertheless useful way: the virtues of global discourse and those of local discourse must find a meeting point and synergy to avoid cultural relativism and localist closures from finding themselves in an explosive alliance with the almighty and mercantile globalist arrogance: the consequences would be and are catastrophic and moreover also frequently observed.
Is there a possible bridging of local and global that makes sure that «the global and the local can become reciprocal instruments in the deepening of democracy» (Appadurai 2002) ? This is the central question that we must ask ourselves if we want to understand why there are so many failures of global health programmes which in turn were conceived to rescue failing local policies in countries with low and middle incomes. Hence, local failures and global failures.
In the fine introductory article of the monographic issue of the Global Public Health journal in March 2010, Stewart, Keusch and Kleinman (Stewart and others 2010) point out that the now historical and proverbial failure of models of primary health care in poor countries is due: a) to the verticality of the programmes that focus on single diseases, b) to the traditional biomedical model of disease control which ignores cultural context and social determinants c) to severe inequalities in access to health care. All too often at least one of these systematic errors can be found in global mental health programs and this also explains the repeated failures.
The distance between understanding local situations and the logic of global programmes is definitely huge and as long as local actors are systematically excluded from the conception, production, assembly and distribution of programmes of intervention that distance will act as an obstacle in the acceptance and implementation of interventions.
There is in fact and often too frequently, a purely ritual adoption of the concept of local, a kind of dutiful acknowledgment of the existence of local actors who are acceted but more as receptacles than protagonists. Of course a politically correct language never expresses the condition of passivity and dependence of the local situation but instead sends reassuring messages on respect for local cultures, languages, specific needs etc. but, without prejudice to these linguistic rituals, there remains a deep conviction of the universality of the western biomedical model and of treatments that are transformed into export goods. Arjun Appadurai, in regards to the relationship between a national state and a local reality, writes that "for the modern national state, locality is a site devoted to nostalgia, celebrations and commemorations functional to the national model, or else it is nothing more than a necessary condition for the production of national citizens. Neighborhoods as social formations, are a source of insecurity for the nation state because usually they contain spaces (more or less extensive) where it is possible that techniques of the national process (birth control, linguistic uniformity, economic discipline, communicative efficiency and political loyalty) do not find a way to be applied or are directly challenged "(Appadurai 2001). We can easily find convincing similarities between what Appadurai describes as the relationship between the national state and local reality when we analyze the relationship between psychiatry as a universal dialogue and model that globalizes in local realities through efficient local agents (psychiatrists) who have chosen the global discourse and do not recognize the demand that the local state formulates anymore. You have to wonder if the deep democracy that Appadurai mentions is not an essential dimension in understanding the contexts in which health plans should be developed: "Deep democracy is the closest democracy, more at hand, the democracy of the neighborhood, of the community, of blood relations and friendship, which is expressed in the daily practices of sharing information, of constructing houses and sanitation, and savings (seen as a basis upon which to establish a federation within this global network ... Deep democracy is a public democracy in that it is interiorized in the lifeblood of local communities and becomes part, on a local level, of the habitus, in the sense made famous by Pierre Bourdieu "(Appadurai 2013).
The major international organizations that belong to the United Nations system, major academic centres of research and teaching, and major international non-governmental organizations certainly have the task of promoting reflection on the great issues of health and development, networking and making available knowledge and good practices, of promoting research and training, of stimulating technical cooperation and international solidarity on issues of health, rights and development. This task however, should be carried out with the continuous concern of maintaining active and critical, through their various expressions and representations, the contribution of local actors namely the health authorities of the countries, professional groups and communities of citizens. It calls for a great effort of exchange, of knowledge, a continuous critical adjustment from global to local and local to global. Any mythologizing of one pole over the other can only be the harbinger of disasters: a global thought that believes itself to be exonerated from the comparison with its own relativity is destined to generate thought and practices of a colonial nature while a local thought believed to be legitimized only by its local roots is destined to generate thought and practices characterized by cultural and social paranoia. It is very likely that the personal dimension of morality (i.e. individuals that operate with different roles and functions on projects constructing collective health) and the collective dimension of rights (i.e. the series of political, social and legal guarantees that every local or national community expresses both as a current conquest or an emancipatory movement) are the vectors for the construction of collective health and for the encounter between global and local tools. The technology ratio of medicine cannot constitute in itself a vector but merely a technical complement of the major vectors: collective rights and an individual morality.
The paradigm of global discourse in the field of health and its dangerous amalgamation and complicity with the interests of the multinational corporations of medicine is also strongly influenced by a function that is assigned to global health by the great powers, that is an instrument of "soft power" as opposed to "hard power" represented by the use of military force. The United States and also Nato make an increasing use of intervention in the health area to facilitate peace-building processes in areas of military intervention, to develop intelligence networks and create consensus in local communities. On the other hand this was often the logic of the internationalist intervention in health of the USSR and Cuba in past decades. Recently in the language of diplomacy the expression "smart power" also appeared concerning the global health discourse as a tool to create bridges and cooperation between private sectors of rich countries, non-governmental organizations and governments of poor countries. The global health discourse is increasingly influential and pervasive even though local suffering doesn't seem to benefit from this expansion that seems to respond more to the needs of the globalized economy rather than local needs. It is very likely that this phenomenon represents a paradigm far beyond the health sector and is also found in other areas such as agriculture, food and environmental resources.


A. Appadurai, Modernity in dust, Meltemi Editore, Rome, 2001, p. 246.
A. Appadurai, "Deep Democracy: Urban Governmentality and the Horizon of Politics" in Public Culture, 2002, 14 (1), pp. 21-47.
A. Appadurai, «Bottom-up Cosmopolitanism», SouQuaderni, 7, 2013, .
Stewart, K.A., Keusch, G.T. Kleinman A., «Values and moral experience in global health: bridging the local and the global», in Global Public Health, 2010, 5:2, pp.115-121.

World Health Organization, Draft Comprehensive Mental Health Action Plan 2013-2020, WHO, Geneva 2012d


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Center for urban suffering

The study centre wishes to study the phenomenon of urban suffering, in other words the suffering that is specific to the great metropolises. Urban Suffering is a category that describes the meeting of individual suffering with the social fabric that they inhabit. The description, the understanding and the transformation of the psychological and social dynamics that develop from the meeting of ...

Who we are

The Urban Suffering Studies Center - SOUQ - arises from Milan, a place of complexity and economic and social contradictions belonged to global world.Tightly linked to Casa della Carità Foundation, which provides assistance and care to unserved populations in Milan (such as immigrants legal and illegal, homeless, vulnerable minorities), the Urban Suffering Studies Center puts attention on ...


Centro studi Souq Management commitee: Laura Arduini, Virginio Colmegna (presidente), Silvia Landra, Simona Sambati, Benedetto Saraceno ; Scientific commitee: Mario Agostinelli, Angelo Barbato, Maurizio Bonati, Adolfo Ceretti, Giacomo Costa, Ota de Leonardis,  Giulio Ernesti, Sergio Escobar, Luca Formenton, Francesco Maisto, Ambrogio Manenti, Claudia Mazzucato, Daniela ...
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ISSN 2282-5754 Souquaderni [online] by SOUQ - Centro Studi sulla Sofferenza Urbana - CF: 97316770151
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