Editorial: Global – national – local

‘…. this was the identity I took to India on my first visit in 1962. And when I got there I found it had no meaning in India. The idea of the Indian community – in effect, a continental idea of our Indian identity – made sense only when the community was very small, a minority, and isolated. In the torrent of India, with its hundreds of millions, where the threat was of chaos and the void, that continental idea was no comfort at all. People needed to hold on to smaller ideas of who and what they were; they found stability in the smaller groupings of religion, clan, caste, family….’ (Naipaul 1998). Nothing could be more appropriate to approach the ‘local’ and the ‘global’ than this narrative. Naipaul captured the problem in his personal experience when he travelled from Trinidad to his roots: the individual is caught in his immediate circumstances which are primarily local, very local. The larger context, the global perspective, has little meaning in local settings, which are determined by tradition; by tightly woven family bounds; by the neighbourhood; by needs; and, at worst, by the need to survive. In this respect the local does not have much to choose from. It is the inherited way of living. The local is where we originated from, on which we dwell in our most intense feelings and relationships. The nation stepped in between, structuring our immediate and wider environment. The global had precursors generations ago, when people went out to discover the world. But only towards the very end of the last millennium did globalization mark an era in its own right. The three levels are by no means discrete; they are intertwining increasingly. The closer we move together, the more we realize how similar and yet how different we are from each other. Views across the fence into each other’s backyards reveal the peculiarities and uniqueness of places despite the omnipresence of ‘McWorld’. The local is simple. It is where we are, the place we are familiar with, where we are brought up and where we bring up our children. It is the place of our own habits and traditions where we follow the most complex rules without even realizing that they are complex. This applies particularly to health perceptions and strategies. The nation is a construct created only a few centuries ago. In terms of numbers it gained momentum with the rapid decolonialization of the twentieth century, when more than 130 states became independent and entered the family of nation-states. It was particularly important to introduce and sustain the principle of sovereignity because most of these nations were too small and weak to defend themselves. Sovereignity not only relates to external affairs but also to responsibilities within, of which public health is a core purview. The global is the most difficult to describe. Certainly, explorers and traders of past centuries opened the globe to knowledge. But their experience of the globe was distinctly different from what we today regard as shared global knowledge, views, behaviours and activities. Technological achievements of the recent past have accelerated globalization: Rail tracks and highways have paved the way into the global village, satellites beam local thoughts into the global think tank. Hobsbawm sees the most substantial difference to the previous century ‘… in the international and interlinguistic standardization of culture …, with at best a slight time-lag, the same films, popular music-styles, television programmes and indeed style of popular living across the world …’ ( 3). Regarding the field of health, the emergence of intergovernmental organizations (IGOs) as part of the political globalization has been particularly relevant. There are approximately 300 IGOs today, the most prominent being the United Nations and its associated agencies, for example the World Health Organization (WHO). New players have entered the field competing and networking with each other: the World Bank, the European Union, philanthropic institutions such as the Bill and Melinda Gates Foundation, and, from the private-for-profit sector and the pharmaceutical industry, to name only the most important ones. The new landscape which is forming is putting everybody on difficult ground and implications are vigorously discussed ( 7). Those are the layers of our problem. How do they interact? – John W. 4 have reformulated this question in an allegory: ‘How would a newly discovered island society be incorporated into world society? A government would soon form looking something like a modern state with many of the usual ministries and agencies. Official recognition by other states and admission to the United Nations would ensue. The society would be analysed as an economy, with standard types of data, organizations, and policies of domestic and international transactions. Its people would be formally reorganized as citizens with many familiar rights, while certain categories of citizens – children, the elderly, the poor – would be granted special protection. Standard forms of discrimination, especially ethnic and gender based, would be discovered and decried. The population would be counted and classified in ways specified by world census models. Modern educational, medical, scientific, and family law institutions would be developed. All this would happen more rapidly, and with greater penetration to the level of daily life, in the present day than at any earlier time because world models applicable to the island society are more highly codified and publicised than ever before. Moreover, world society organizations devoted to educating and advising the islanders about the models’ importance and utility are more numerous and active than ever. Figure 1 There is a global creation of locality and not so much the presence of global artefacts in the local... Wuhan, China, October 2000 What would be unlikely to happen is also clear. Theological disputes about whether the newly discovered Indios had souls or were part of the general human moral order would be rare. There would be little by way of an imperial rush to colonize the island. Few would argue that the natives needed only modest citizenship or human rights or that they would best be educated by but a few years of vocational training. Thus, without knowing anything about the history, culture, practices, or traditions obtained in this previously unknown society, we could forecast many changes that, upon ‘discovery’, would descend on the island under the general rubric of “development”. Our forecast would be imprecise because of the complexity of the interplay among various world models and local traditions, but the likely range of outcomes would be quite limited. We can identify the range of possibilities by using the institutionalist theoretical perspective … to interpret what has already happened to practically all of the societies of the world after their discovery and incorporation into world society.’, Meyer’s story of the hitherto untouched island suggests that there is not much room to play. A process of institutionalization is clearly visible, in which there is a global creation of locality and not so much the presence of global artefacts in the local ( 6). What is happening goes far beyond snapshots of trademarks on dislocated T-shirts. It appears unresolved to date whether we are tumbling ever faster straight into Barber’s ‘McWorld’ ( 1992) or whether the local is strong enough to withstand or modify this overwhelming trend. Figure 2 The local is on which we dwell in our most intense feelings and relationships … Southern Germany in the 1990s. Let us focus on health issues, a particularly difficult terrain with an increasing diversity of global players beaming their messages on health strategies to ministries of health and beyond. At a time when the map of actors in the health field was much less complex, 2 saw where the problem lies: ‘Clearly governments can trust no formulas devised in Geneva or elsewhere, but must create the simple machinery necessary to define and resolve their own problems, locality by locality.’ In our new occasional series ‘global – national – local’ we will cover important issues in noncommunicable and communicable diseases. The first contribution to the series deals with mental health from the global perspective, from that of the Indian subcontinent, and from the viewpoint of an urban slum area in Mumbai and a rural area in West Bengal ( 8). It is the very purpose of this series to contrast and compare the local, the national, and the global on important health issues and to initiate a debate on the state of affairs, interactions and prospects for the future.