WHAT IS NURSING’S ROLE IN INTERNATIONAL AND GLOBAL HEALTH?

Nursing has a long history of service to the global community.1 But, is service the only role needed for nursing globally? What about nursing’s call to expand beyond the service role? In this editorial, I challenge nurses in all geographic locations to consider developing, integrating and weaving their role as clinical health care providers with that of advocate, artist, activist, scholar and citizen.2 The concept of globalization has been hotly debated over the last several decades. In my view, globalization is not merely increased communication and ease of cultural exchange worldwide. Rather, it is intricately connected to the “development of market power and to the consolidation of economic institutions worldwide”.3:7 Globalization is extremely advantageous to some, particularly to members of the wealthy classes worldwide, while it is often devastating to the poor and disenfranchised. Economic globalization is closely related to neoliberal reforms and the push to expand free markets through increased privatization, deregulation and decentralization.4 In a neoliberal environment, severe cuts are made in public health and social welfare systems while the private sector and capitalist enterprises are privileged. The lean economy of a decade ago and the austerity programs being thrust on nation states by the International Monetary Fund and World Bank today are examples of the longstanding, intensive push toward economic neoliberalism. How does nursing fit into a globalized world of economic power and privilege and what role should nursing play vis-à-vis international and global health? Nursing, at least nursing in the United States, has directed much attention to responding to the changing health needs that came about as a result of globalization (that is, as a result of increased longevity, increasing obesity, cardiovascular disease and other health trends) and on the development of health promotion action to reverse negative health trends.5 Nursing in the north has integrated some international and global health concepts into the nursing curriculum. However, it has focused primarily on integrating clinical topics such as the global spread of communicable diseases, the need for evidenced-based nursing interventions, meeting the needs of vulnerable populations, and addressing issues of cultural diversity and sensitivity.6 Regarding health problems that exist around the world, U.S. nursing has interpreted international and global health primarily from a clinical perspective. Viewing international and global health in relation to clinical health issues places emphasis on the problem, (e.g. poor health, disease, pathology), with little attention to the cause or origin of the issue (e.g. economic, social and political elements). Focusing on the origins of international and global health issues requires an analysis of the political economy of health and an understanding of the structural issues which underpin health and social issues. How can all nurses (who are excellent clinical practitioners) expand their role to become human rights advocates, political activists, engaged citizens and critical artists for global issues? Acquiring these roles requires that nurses have a sound understanding of globalization and the political economy of health, as well as a solid knowledge base in human rights and global health diplomacy. Serious attempts have been made lately on the global scene to prioritize health as a policy issue while increasing awareness of the connection between foreign policy and health.7 In 2009, the United Nations General Assembly passed an official resolution to this effect. Also, individual countries have passed their own mandates. Brazil, for example, stands on the forefront of this action by supporting both the concept of global health diplomacy and the WHO Commission on Social Determinants of Health.7 Additionally, Latin America and Brazil have a respected history of international health endeavors. Amidst formidable challenges in the 20th century, “health scholar-activists” throughout Latin America and Brazil “developed bold new ideas and practices around social medicine, collective


WHAT IS NURSING'S ROLE IN INTERNATIONAL AND GLOBAL HEALTH?
Nursing has a long history of service to the global community. 1 But, is service the only role needed for nursing globally? What about nursing's call to expand beyond the service role? In this editorial, I challenge nurses in all geographic locations to consider developing, integrating and weaving their role as clinical health care providers with that of advocate, artist, activist, scholar and citizen. 2 The concept of globalization has been hotly debated over the last several decades. In my view, globalization is not merely increased communication and ease of cultural exchange worldwide. Rather, it is intricately connected to the "development of market power and to the consolidation of economic institutions worldwide". 3:7 Globalization is extremely advantageous to some, particularly to members of the wealthy classes worldwide, while it is often devastating to the poor and disenfranchised.
Economic globalization is closely related to neoliberal reforms and the push to expand free markets through increased privatization, deregulation and decentralization. 4 In a neoliberal environment, severe cuts are made in public health and social welfare systems while the private sector and capitalist enterprises are privileged. The lean economy of a decade ago and the austerity programs being thrust on nation states by the International Monetary Fund and World Bank today are examples of the longstanding, intensive push toward economic neoliberalism.
How does nursing fit into a globalized world of economic power and privilege and what role should nursing play vis-à-vis international and global health? Nursing, at least nursing in the United States, has directed much attention to responding to the changing health needs that came about as a result of globalization (that is, as a result of increased longevity, increasing obesity, cardiovascular disease and other health trends) and on the development of health promotion action to reverse negative health trends. 5 Nursing in the north has integrated some international and global health concepts into the nursing curriculum. However, it has focused primarily on integrating clinical topics such as the global spread of communicable diseases, the need for evidenced-based nursing interventions, meeting the needs of vulnerable populations, and addressing issues of cultural diversity and sensitivity. 6 Regarding health problems that exist around the world, U.S. nursing has interpreted international and global health primarily from a clinical perspective.
Viewing international and global health in relation to clinical health issues places emphasis on the problem, (e.g. poor health, disease, pathology), with little attention to the cause or origin of the issue (e.g. economic, social and political elements). Focusing on the origins of international and global health issues requires an analysis of the political economy of health and an understanding of the structural issues which underpin health and social issues. How can all nurses (who are excellent clinical practitioners) expand their role to become human rights advocates, political activists, engaged citizens and critical artists for global issues? Acquiring these roles requires that nurses have a sound understanding of globalization and the political economy of health, as well as a solid knowledge base in human rights and global health diplomacy.
Serious attempts have been made lately on the global scene to prioritize health as a policy issue while increasing awareness of the connection between foreign policy and health. 7 In 2009, the United Nations General Assembly passed an official resolution to this effect. Also, individual countries have passed their own mandates. Brazil, for example, stands on the forefront of this action by supporting both the concept of global health diplomacy and the WHO Commission on Social Determinants of Health. 7 Additionally, Latin America and Brazil have a respected history of international health endeavors. Amidst formidable challenges in the 20 th century, "health scholar-activists" throughout Latin America and Brazil "developed bold new ideas and practices around social medicine, collective health, and citizen inclusion". 8:108 A good number of nurses are involved in these efforts across the entire southern continent.
Global health diplomacy is a relatively new concept. It is a transdisciplinary endeavor blending and synthesizing knowledge from "international relations, culture, and politics with medicine and other health sciences to step beyond the disciplinary boundaries of each of these fields". 9:316 Global health diplomacy has two goals: to improve global health and to enhance international relations particularly, but not exclusively, in struggling areas of the world. 9 Global health diplomacy addresses, among other things, urgent human rights issues.
The discipline of nursing is ideally placed to engage its members as actors in both human rights and global health diplomacy efforts. While retaining its position as providers of expert health care service to the global community, nursing can also assume new roles. For example, nurses in many geographic locations have the ability to partner with other professionals in transdisciplinary initiatives to improve health and to enhance human rights and international relations efforts. Also, the profession's long history of service to the global community can grow and develop into one where nurses also take on leadership roles "to examine health in the context of the global order of political and economic power". 8:107 Brazilian and Latin American nursing has solid experience in human rights advocacy and a good understanding of health and pro-social global action. 3 Also, nurses from these countries have substantial familiarity with international health efforts that acknowledge social justice needs. 8 Nurses in Brazil and Latin America can: 1) serve as role models for nurses in the U.S.A and beyond, 2) be the impetus for other nurses to incorporate this knowledge, and 3) help nurses develop the roles of international and global human rights advocates, activists, citizens and artists.

Karen Lucas Breda
Ph.D., University of Hartford, West Hartford. Connecticut, United States of América.