Claudio Schuftan, MD
Creative Nursing Vol 27 #3, August 2021
As Duty Bearers, nurses are prime guardians, not only of the right to life (as stated in Article 3 of the United Nations Universal Declaration of Human Rights: “Everyone has the human right to life, liberty, and security”), but also the rights of women, the rights of children, and the rights of people in minority groups, among others. As Claim Holders, nurses have substantial claims towards labor rights, economic rights, maternity rights, and social protection rights, among others. This article presents systematic information about social determinants of health and explores nurses’ inherent obligations in this domain, suggesting that nursing education must innovate, adding a human rights component to address the role of Promoters of Social Change,
Key words: human rights; nursing education; social determinants of health; professional social responsibilities; need for a new commitment
When analyzing any human rights issue, it is essential to identify two main groups of actors: Claim Holders (also called Rights Holders in some literature) and Duty Bearers. Claim Holders are individuals or social groups that have particular entitlements in relation to specific duty-bearers. In general terms, all human beings are rights holders under the Universal Declaration of Human Rights (Right to Education Initiative [RTE], 2017). Duty Bearers are those actors who have a particular obligation or responsibility to respect, promote, and realize human rights and to abstain from human rights violations (RTE, 2017).
As duty bearers, nurses are very much guardians of the right to life, as stated in Article 3 of the Universal Declaration of Human Rights: “Everyone has the right to life, liberty and security of person” (United Nations, 1948); the rights of women; the rights of children; the rights of people in minority groups; and the rights of LGBT people, among others.As claim holders, nurses have substantial claims on labor rights, economic rights, maternity rights (e.g., the rights to paid maternity leave and to breastfeed in the workplace), and social protection rights (e.g., equal pay, workers’ and high-risk work compensation, personal protective equipment, sick leave, and retirement benefits). Nurses may feel pressured to keep silent when those rights are not upheld, but these grievances clearly need to be aired openly in order to express prevailing discontents about, and to be prepared to claim, the above rights in a drive to strengthen the current status of the nursing profession.
But beyond these rights, and as an ethical question for all health professionals, nurses have an additional role as Promoters of Social Change. Nurses cannot but be involved in dynamic social processes beyond their involvement with individual patients. The challenge also involves nurses engaging in critical analysis of prevailing values, including the use of the language of human rights (Tseng et al., 2002).
The reader may ask: Why is creative thinking on human rights important for nurses? This relates to another question: What is the non-clinical critical role of nurses in society? Here are ways to consider these questions in a new perspective that will help make needed connections, using often divergent, out-of-the-box thinking.
Nurses’ inherent obligations in the social realm
Discussion about social change is at the very heart of daily health work. As health professionals, particularly but not only in the public health sphere, nurses are not a class apart. They are responsible not only to their own personal needs, but they are duty-bound to immerse themselves in the societies they are part of. This is because they are seen as natural leaders in their communities, destined not only to provide better ideas that can reshape health services, but also to make sure that those ideas are implemented (Cohen & Reutter, 2007).
But when it comes to reshaping health services, are nurses really listened to? Or do physicians dominate the stage? Unfortunately, some doctors bend the rules of the prevailing discourse to suit their own interests, minimizing the need to make structural changes; they argue primarily for what they want, ignoring other members of the health team and ignoring their role as promoters of social change. Too often they justify the status quo and the existing privileges of certain groups according to class, race, or gender (Basu et al., 2017).
The judgment of the work of nurses depends on whether it conforms to the political convictions of those who are judging – and these individuals are mostly self-appointed. Nurses are not independent intellectuals floating somewhere above the economic system: all health professionals are part of it. So, the question is: Is it an exaggeration to say that, as is true for physicians, nurses perpetuate the social and political passivity that has become part of the image they can be judged by? Together with other health-care professionals, are nurses thus prisoners of their own past highly technical training and, often, of somebody else’s thoughts on social issues? (Metzl, 2014). If so, does being prisoners mean that nursing students learn only technical data in their curricula, while socially unaware nurse educators or other academic elites barely cover the harsh social realities anywhere in the world that future nurses ought to be considering?
For example, measuring poverty and its effects on health can often be a substitute for, or an excuse for, not acting in response to perfectly visible needs. There is a tendency to stop the analysis where politics begins, with formulations such as, “This, however, is a political question.” Of course, that is often where the analysis should start! Not only in clinical, but also in public health work, the task is not merely to denounce violation of the right to health, but to reflect and to do something about it. It is the principle of recognizing trends and acting promptly at the right time that differentiates politically oriented health professionals (including nurses) from theoreticians.
I believe that nurses do have inherent obligations in the area of human rights. They cannot retreat into helpless passivity, watching the social causes of preventable ill health and preventable deaths around them increase. Nurses can alter trends and avert catastrophes if they recognize and exercise their own power to make a difference, especially if they organize around these topics.
One of the greatest challenges facing humanity today is the challenge of meeting the fundamental human rights of people rendered poor. Health professionals should look beyond academicism at real people and their needs. Clearly, there is no easy or short-term solution to the prevailing syndrome of preventable ill health and deaths. The perniciousness of the technocratic approach to tackling preventable ill health is that it has so many non-solutions built in, masquerading as fitting responses. Traditional public health plans, while they may purport to being committed to greater equity and equality, do not necessarily contain interventions conducive to attaining a more egalitarian society.
Nurses as health professionals: need for a new commitment
As health workers, nurses need to adopt a more proactive course of action on their own behalf (labor and other issues) and on the behalf of those they serve (e.g., right to health issues). But also ponder, some of us in the health profession are doing quite nicely; we may have a vested interest in the status quo and fail to expose the unintended negative consequences of well-intended measures – and this often is downright dangerous. Colleagues in the profession may point out valid discrepancies between the current political economy of health and the harshness of reality on the ground, but they are often disciplined rather than rewarded by the guardians of the paradigm.
Yes, I acknowledge we all have limitations. So, I ask: Is it thus fair to say that we keep diagnosing the obvious and giving prognosis of a tragedy? Why do we keep emphasizing solutions within the health sector that deal with what is deemed immediately important, and not with what is fundamental for the right to health? Everything is important, but what is fundamental? As I see it, the help given to needy groups is important, but the promotion of more sustainable, permanent structural social changes is fundamental.
We keep making projections of trends that we do not want to continue. Trends are not destiny. The destiny is in our hands. It is useless to take care of the sick and malnourished while the determinants of preventable ill health and malnutrition are not tackled, with decisions delayed by a system that is not synchronized with what is truly happening. These social determinants of health, the economic and social conditions that influence individual and group differences in health status, are factors found in one’s living and working conditions (such as the distribution of income, wealth, influence, and power) rather than individual risk factors (such as behavioral risk factors or genetics); the distribution of social determinants is often shaped by public policies that reflect the prevailing local political ideology (Powell, 2018). Paradoxically, most of the strategies for eradicating poverty have been directed at those rendered poor themselves, but not at the economic systems that produce poverty (Schuftan, 2012). Projects dreamed up in a social vacuum must play themselves out in the real world of injustice and conflict. We need health experts who are strong and flexible enough to ask the right questions rather than sell the wrong answers.
In search of new roles and responsibilities for nurses
The problem with developments in public health is that too often health professionals may be trying to find reducible solutions to irreducible problems. Technological advances can address reducible problems, but too many hope these will solve the irreducible problems as well. When the world is messy, one falls back either on ideology or on technology. Responding to the seduction of technology is more independent of experience – one does not have to know much. But the wrong technologies have for too long been destroying genuine community life and have led to maldevelopment, the qualitative notion that expresses the mismatch (prominent in health care) between the prevailing economic, political, and cultural conditions and the needs and means of the people (Amin, 1990).
Conflict is common where there are competing interests. Avoiding conflict, as health professionals often do, is no solution. Conflict is not necessarily violence. Conflict is a necessary means to attaining true dialogue with duty bearers in authority.
Why then not change our order of thinking rather than trying to conquer preventable ill health and malnutrition with the use of technology? Technology is basically improvisational. It treats the symptoms, but provides no lasting cures. In health care, the predominant reliance on technology is part of the problem. New policies will thus require patient and possibly painful re-education of all on the health team. A technocratic utopia is the most banal of all utopias. “Utopia is on the horizon. I move two steps closer; it moves two steps further away. I walk another ten steps and the horizon runs ten steps further away. As much as I may walk, I’ll never reach it. So what’s the point of utopia? The point is this: to keep walking.” (Galeano, 2016)
Hence, the best way to predict the future is to create it. So, this is a call for nurses, not only to take charge of constraints in their professional lives, but also engage more on the humanitarian and human rights issues of the profession. If such a goal seems utopian or overwhelming, starting small can deliver daily victories.
The future challenge
The real challenge in our present world is to reorganize our society to minimize suffering. Human happiness is undefinable; human suffering is concrete and painfully visible – especially to nurses. It manifests itself as preventable sickness and deaths, unemployment, poverty, gender violence, illiteracy, and ignorance.
Developments in health have to ultimately lead to liberation. Any action that gives people/patients more control over their own health affairs is an action for development. But such a health development needs to be built from the bottom up. Otherwise, we have social Darwinism, i.e., the ones who make it are the richest, the most powerful, the whitest, and the malest (Perlman, 1982; Schuftan, 2008).
A program of consciousness raising directed at the public health community – importantly, to nurses, given their closeness to patients – is needed. Public health must bring to the general public systematic knowledge of the social determinants of health, a knowledge that is critical in the choice of strategies for sustainable change in health (World Health Organization, 2008). New forms of education, lifelong learning, continuing education, awareness creation, and consciousness raising need to be advanced in this endeavor that aims at stronger involvement of nurses to promote this transition and to provide rallying points for mobilization in the direction of the fulfillment of the right to health.
References:
Amin, S. (1990). Maldevelopment: Anatomy of a global failure. UN University Press. ISBN-10: 0862329302 https://unu.edu/publications/books/maldevelopment-anatomy-of-a-global-failure.html
Basu, G., Pels, R.J., Stark, R.L., Jain, P., Bor, D.H., & McCormick, D. (2017). Training internal medicine residents in social medicine and research-based health advocacy: A novel, in-depth curriculum. Academic Medicine, 92(4), April. 515-520(6) doi: https://doi.org/10.1097/ACM.0000000000001580
Cohen, B. & Reutter, L. (2007). Development of the role of public health nurses in addressing child and family poverty: A framework for action. Journal of Advanced Nursing 60(1), 96-107. doi: https://doi.org/10.1111/j.1365-2648.2006.04154.x
Galeano, E. (2016). https://www.youtube.com/watch?v=jsSqpATmAmU
Metzl, J.M., (2014). Physicians as agents of social change. AMA Journal of Ethics, 16(9) E671-781, Sept.
Perlman, J. (1982). Society for International Development meeting, Horizons, USAID Washington, 36.
Powell, D. L., (2018). Cultural competence is not enough. Creative Nursing, 22(1). doi: 10.1891/1078-4535.22.1.5 .
Right to Education Initiative (RTE). (2017). Glossary. https://www.right-to-education.org/monitoring/node/2725/
Schuftan, C. (2008). An ethical question: Are health professionals’ promoters of status-quo or of social change? Promotion & Education, 15(3), 30-3. doi: 10.1177/1025382308095655.
Schuftan, C., (2012). Poverty and the violation of human rights: A proposed conceptual framework. International Journal of Health Services. 42(3), 485-498.
Schuftan, C. (2019). Actions and activism in fostering genuine grassroots participation in health and nutrition. World Nutrition. 10, 148-152
Tseng, V., Chesir-Teran, D., Becker-Klein, R., Chan, M.L., Duran, V., Roberts, A., & Bardoliwalla, N. (2002). Promotion of social change: A conceptual framework. American Journal of Community Psychology, 30(3), 401-27. doi: https://doi.org/10.1023/A:1015341220749
United Nations (UN). (1948). Universal Declaration of Human Rights. https://www.un.org/en/about-us/universal-declaration-of-human-rights
World Health Organization (WHO). (2008). Social Determinants of Health. Retrieved from https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
PULL QUOTES
It is the principle of recognizing trends and acting promptly at the right time that differentiates politically oriented health professionals (including nurses) from theoreticians.
Nurses can alter trends and avert catastrophes if they recognize and exercise their own power to make a difference, especially if they organize around these topics.
Correspondence about this article should be addressed to Claudio Schuftan at schuftan@gmail.com
Claudio Schuftan, MD, (he/him), is a public health and human rights specialist residing in Vietnam. He publishes regularly on these topics at www.claudioschuftan.com. He is a member and cofounder of the People’s Health Movement. As a consultant, he has worked in over 50 countries. He is particularly interested in the teaching/disseminating these topics for health professionals.