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NURSI NG I N THE ERA OF GLOBALI SATI ON: CHALLENGES FOR THE 2 1
STCENTURY
Alcione Leit e da Silva1
Silva AL. Nursing in t he era of globalisat ion: challenges for t he 21st cent ur y. Rev Lat ino- am Enfer m agem 2008
j ulho- agost o; 1 6 ( 4 ) : 7 8 7 - 9 0 .
The pur pose of t his paper w as t o r eflect about issues r elat ed t o t he pr ocesses of globalizat ion and t he global
im pact s on h ealt h , poin t in g ou t som e ch allen ges for Nu r sin g in t h e t w en t y - fir st cen t u r y . I n t h is sen se, t h e
aut hor out lines t he for m s and t r ends of globalizat ion in t he cont em por ar y w or ld, and t he dr ast ic im pact s on
hum an healt h and environm ent . To respond t o t he challenges of t he globalized world, som e ways are indicat ed,
am ong w hich, t he st r engt hening of nur sing discipline st ands out , t oget her w it h som e guidelines for educat ion,
r esear ch and Nur sing car e, in a local and global scope.
DESCRI PTORS: healt h; nur sing
ENFERMERÍ A EN LA ERA DE LA GLOBALI ZACI ÓN: RETOS PARA EL SI GLO XXI
El obj et ivo de est e t ext o encont rar un m om ent o para reflexionar sobre los aspect os relacionados a los procesos
de globalización, así com o sobre los im pact os en la salud global señalando algunos desafíos para la Enferm ería
en el siglo XXI . En est e sent ido, la aut or a esboza los cont or nos y t endencias de la globalización en el m undo
cont em poráneo, así com o los drást icos im pact os en la salud hum ana y am bient al. De est a form a, para responder
a est os aspect os, señala algunos cam inos ent r e los cuales se dest acan el for t alecim ient o de Enfer m er ía com o
disciplina y el est ablecim ient o de dir ect ivas en educación, invest igación y cuidado en Enfer m er ía, en el ám bit o
r egional y m undial.
DESCRI PTORES: salu d; en f er m er ía
A ENFERMAGEM NA ERA DA GLOBALI ZAÇÃO: DESAFI OS PARA O SÉCULO XXI
O obj et ivo dest e t ext o foi abrir espaço para reflexão acerca de quest ões relat ivas aos processos de globalização
e im pact os na saúde global, apont ando alguns desafios par a a Enfer m agem no século XXI . Nesse sent ido, a
aut or a delineia os cont or nos e t endências da globalização no m undo cont em por âneo e os im pact os dr ást icos
n a saú de h u m an a e n o m eio am bien t e. Par a r espon der aos desaf ios do m u n do globalizado, apon t a algu n s
cam in h os, den t r e os qu ais se dest acam o for t alecim en t o da disciplin a de En fer m agem e algu m as dir et r izes
par a a educação, pesquisa e cuidado de Enfer m agem , em âm bit o local e global.
DESCRI TORES: saú de, en f er m agem
1Post - doct oral degree, Facult y, Universit y of Aveiro, Port ugal, e- m ail: alsilva@ua.pt Rev Latino-am Enfermagem 2008 julho-agosto; 16(4):787-90
www.eerp.usp.br/rlae
Disponible en castellano/Disponível em língua portuguesa SciELO Brasil www.scielo.br/rlae
788
I NTRODUCTI ON
G
lob alizat ion is u n d er st ood b y t h ose w h ofollow a neoliberal ideology as an irreversible process
w h ich is in t en sif ied an d d ev elop ed accor d in g t o it s
o w n l o g i c a n d d y n a m i c s . To o t h e r p e o p l e( 1 - 2 ),
g lob alizat ion g oes b ey on d d et er m in ism , b ecau se it
b ecom es a f ield of social an d p olit ical q u est ion in g .
Som e aut hors also say t hat globalizat ion is especially
econ om ic( 3 ), an d it can also b e seen as a com p lex
a n d d i v e r se p h e n o m e n o n , w i t h e co n o m i c, so ci a l ,
polit ical, and cult ur al dim ensions, am ong ot her s( 1- 2).
Wit h t his diversit y in t he speeches, as of t he
80’s, globalizat ion t ook several shapes and t endencies,
t here are, at t im es, conflict ing. However, t he negat ive
im pact of globalizat ion on t he ev er y day liv es and on
t he healt h of people in t he global sphere is undeniable,
esp ecially of t h ose econ om ically d ep r iv ed of g ood s
and basic social services such as educat ion, and healt h
ca r e.
Wit hin t his cont ex t , Nur sing is challenged t o
look for new ways of m eet ing crit ically and effect ively
t he dem ands of t hese healt h issues t hat ar e put t o
societ y. Fr om t his set t ing, t he pr esent t ex t dev elops
som e r ef lect ion s on t h e f ollow in g issu es: Wh at ar e
t h e h ealt h per spect iv es in t h e er a of globalizat ion ?
Wh at ar e t h e ch allen ges im posed t o Nu r sin g in t h e
2 1st cent ur y ?
W HAT ARE THE HEALTH PERSPECTI VES I N
THE ERA OF GLOBALI ZATI ON?
I n t i m e s o f g l o b a l i za t i o n , i n h e a l t h , i t i s
i m p o r t a n t t o h i g h l i g h t t h e p o si t i v e a d v a n c e s i n
co m m u n i ca t i o n a n d b i o t e ch n o l o g y. Ho w e v e r, t h e
effect s of globalizat ion on t he healt h of t he world poor
populat ion t ends t o be far m ore negat ive t han posit ive,
sin ce pov er t y is closely r elat ed t o h ealt h con dit ion s
and ex pect at ions. I t is w or t h m ent ioning t hat of t he
w or ldw ide popu lat ion of 6 billion people, 2 . 8 billion
( alm ost half ) live w it h less t han 2 dollars a day, and
1.2 billion ( one fift h) wit h less t han 1 dollar a day, and
44% live in t he Sout h of Asia( 4).
I n t his sense, poor count ries are account able
for 90% of t he diseases of t he world, but t hey do not
h av e ov er 1 0 % of t h e r esou r ces g lob ally sp en t in
h e a l t h , w h i ch i s r e f l e ct e d i n t h e p o o r e co n o m i c
dev elopm en t of t h ese cou n t r ies, du e t o t h e loss of
people at a young and pr oduct ive age. Childr en w it h
less t h an f iv e y ear s old in Af r ica ar e 7 t im es m or e lik ely t o die t h an Eu r opean ch ildr en , j u st as people
f r om 1 5 - 5 9 y ear s old in Af r ica ar e 4 . 5 t im es m or e lik ely t o d ie t h an p eop le in Eu r op e, an d m at er n al
m ort alit y rat es are 16 t im es great er in Africa t han in Eu r ope( 5 ).
A risk t o w orld healt h due t o globalizat ion is con n ect ed w it h in cr ease in t r an sn at ion al t r ade, an d
t his is a direct cause of t he spread of diseases( 6), such as hepat it is B virus, due t o t he int ernat ional t rade of
blood product s, diseases relat ed t o t he int ake of food, bovine spongiform encephalopat hy, and t hose relat ed
t o n ew v a r i a t i o n s o f Cr eu t zf el d t - Ja k o b d i sea se i n
h u m an bein gs.
Har m s t o t h e ph y sical en v ir on m en t , lar gely
cau sed b y u n su st ain ab le con su m p t ion r at es of r ich c o u n t r i e s , c a n b e s e e n a s a c o n s e q u e n c e o f
globalizat ion . Th e har m t o t he env ir onm ent h as led t o alar m ing loss of social env ir onm ent al qualit y, w it h
a great result in t he populat ion healt h, m aking it clear
t h at a g lob al f u t u r e w ou ld n ot b e v iab le w it h ou t a st r at egic pr ogr am on sust ainable dev elopm ent .
Risk s t o global healt h r esult , also, fr om t he g r o w i n g u r b a n i z a t i o n , e n c o u r a g e d b y e c o n o m i c
g r o w t h a n d i n d u s t r i a l d e v e l o p m e n t t h a t b r i n g significant social, econom ic, and polit ical changes. This
out com e has negat ive im pact s on t he healt h of people e sp e ci a l l y d u e t o t h e t h r e a t e n o f co m m u n i ca b l e
diseases, as well as t he worsening of ot her problem s associat ed w it h social disint egr at ion and v iolence.
We know t hat good healt h depends, also, on
t he qualit y of healt h policies and healt h invest m ent s( 7), a s w e l l a s e d u c a t i o n , i d e a s , t e c h n i q u e s , a n d
t echnologies. However, poor count ries not only invest lit t le in healt h and educat ion, but also lack financial
a n d h u m a n r e s o u r c e s t h a t e n a b l e a n e q u a l p a r t i ci p a t i o n o f t h e se co u n t r i e s i n i n t e r n a t i o n a l
organizat ions, where decisions affect ing and designing t he r ules oper at ing int er nat ional sy st em s ar e m ade.
These ar e only som e im pact s on healt h due t o t he globalizat ion pr ocess. Cer t ainly, t he im pact of
g lob alizat ion on h ealt h is a com p lex p r ocess, w it h
d i f f e r e n t si d e s, w h o se d i m e n si o n i s f a r f r o m t h e perspect ive focused here. We have a m aj or challenge,
t hat we m ust face if we agree wit h t he Declarat ion of A l m a - A t a , 1 9 7 8 , w h i c h s t a t e s t h a t h e a l t h i s a
f u n d a m e n t a l h u m a n r i g h t a n d t h a t a t t a i n i n g t h e highest possible lev el of healt h is a m ost im por t ant
w o r l d - so ci al g o al s, w h o se r eal i zat i o n r eq u i r es t h e
act ion of m any ot her social and econom ic sect or s in addit ion t o t he healt h sect or( 8).
Rev Lat ino- am Enferm agem 2008 j ulho- agost o; 16( 4) : 787- 90 w w w .eer p.usp.br / r lae Nursing in the era of globalisation…
789
W HAT ARE THE CHALLENGES I MPOSED BY
GLOBALI ZATI ON TO NURSI NG I N THE 21ST
CENTURY?
Over a lit t le m ore t han a cent ury, Nursing, in
different places of t he world, has gone t hrough several
ch an g es, w it h u n d en iab le d ev elop m en t s, t h at w er e
se e n i n t h e a ca d e m i c f i e l d , a n d t h a t l e d t o t h e
achievem ent of new places of act ion( 9). How ever, t he
shape and t r ends of t he globalizat ion pr ocess in t he
c o n t e m p o r a r y s o c i e t y, i m p o s e s n e w a n d g r e a t
ch allen g es f or Nu r sin g , in t h is 2 1 st cen t u r y. Th ese
ch al l en g es ar e d u e, m ai n l y, t o cou n t l ess an d f ast
changes in t he polit ical, econom ic, social, and cult ural
field wit h drast ic effect s on t he individual and collect ive
h ealt h .
Due t o t he com plexit y of t hese processes and
challenges, it is essent ial t o st r engt hen t he discipline
o f Nu r si n g . Th i s st r e n g t h e n i n g g o e s t h r o u g h t h e
const r uct ion of innov at iv e epist em ological bases t hat
ar e in ag r eem en t w it h t h e con t em p or ar y ad v an ces
t h at ar e con sist en t an d sen sible t o t h e h u m an an d
en v i r o n m en t al n eed s an d t h o se o f so ci et y. Th ese
epist em ological bases will, in t urn, support and direct
t h e pr of ession al pr act ice con n ect ed w it h edu cat ion ,
r esear ch, and car e, locally and globally speak ing.
I n t his 21st cent ury, it is essent ial t o com bine
collabor at iv e effor t s in Nur sing, in each count r y and
in t he differ ent count r ies t o open up and consolidat e
sp a ce s o f e f f e ct i v e a ct i o n r e g a r d i n g : 1 ) f o r m i n g
com pet ent scient ist able t o t hink crit ically in order t o
define and priorit ize social needs t hat guide t heir st udy
o b j ect ; t o a ssess t h e v u l n er a b l e a sp ect s o f t h ei r
educat ion, and t o m ak e decisions t o st r engt hen and
c o n s o l i d a t e Ex c e l l e n c y i n c a p a c i t y - b u i l d i n g a n d
s c i e n t i f i c p r o d u c t i o n ; 2 ) p r o d u c i n g i n n o v a t i v e
k n ow led g e an d w it h sizeab le im p act on t h e social
realit y and in t he healt h and well being of individuals,
f am ilies an d com m u n it ies, especially f or t h e poor er
populat ion w it h no access t o goods and ser v ices; 3)
giv ing oppor t unit y t o capacit y - building in t he use of
n ew t h eor et ical an d m et h od olog ical r ef er en ces an d
giv ing t r aining in adv anced t echnological st r at egies;
4) encouraging developm ent of a “ ..proact ive behavior
of Nur sing leader s t o giv e at t ent ion t o oppor t unit ies,
t o cr eat e spaces and m echanism s t o inser t t his field
o f k n o w l ed g e, an d t o p r esen t t h e d em an d s u si n g
pr oj ect s t h at w or k t oget h er w it h pu blic policies” ( 1 0 ),
g ear ed t o t h e social n eed s. How ev er, t h is p r ocess
r equ ir es, abov e all, m u lt icu lt u r al dom ain , sen sibilit y
t o deal w it h differ ences, and abilit y t o build br idges
bet ween t he different boundaries of hum an living in a
global scope.
The power of research in Nursing m ust be t o
consider it as an im port ant space for care, as a polit ical
act iv ism , n ot on ly t o bu ild n ew t h eor et ical- pr act ical
fram ew or k but also, and m ainly, t o per for m act ions
t o increase levels of qualit y of life in societ y( 11).
I n t h e field of for m al edu cat ion in Nu r sin g,
w e hav e t o sear ch for, obligat or ily, an em ancipat ing
e d u c a t i o n , a s a n i m p o r t a n t d i m e n s i o n t o f o r m
professionals wit h crit ical abilit y of t hinking about t hem ,
t hink ing globally about t he pr esent st r uct ur es, fr om
t h e i r h i st o r i ca l r o o t s, a n d a ct i n g l o ca l l y t o so l v e
pr oblem s, in a t r ansfor m ing w ay and w it h social and
ecological r espon sibilit y. Th e edu cat ion n eeds t o be
com m it t ed wit h preparing nurses able t o, am ong ot her
aspect s, : 1) k now about local and global r ealit y ; be
a w a r e o f t h e h e a l t h p r o f i l e o f t h e p o p u l a t i o n ,
r egionally, nat ionally and int er nat ionally speak ing; 2)
w or k in t he sever al levels of com plexit y of individual
an d collect iv e h ealt h car e, w it h social r espon sibilit y
a n d co m m i t m e n t w i t h ci t i z e n sh i p ; 3 ) d e v e l o p a
cult urally com pet ent pract ice, t hat values and respect s
differences in t he scope of gender, sexual orient at ion,
am ong ot her aspect s; 4 ) build k now ledge as of t he
edu cat ion al pr act ice.
I n t he cont ex t of car e, som e st r at egies ar e
n ecessar y, f ocu sin g essen t ially on p eop le, g u id in g
t h em t o em an cipat ion an d au t on om y, m ak in g t h em
capable of t h in k in g an d act in g cr it ically t o im pr ov e
t heir lives. Likewise, t o value and encourage believes
an d cu l t u r al v al u es ar e essen t i al t o p er f o r m car e
cult urally com pet ent , favoring building at t it t udes, and
h ealt h beh av ior s.
The int ent ion in t his t ext was t o open up space
for r eflect ion on som e issues r elat ed t o globalizat ion
pr ocesses and im pact s on global healt h, point ing out
som e im plicat ion s in Nu r sin g. Nat u r ally, t h e cu t w e
have used reduces significant ly t his com plex and plural
realit y. Wit hin t his cont ext , we have t o ask ourselves:
w here should w e go from here? Any pat h w e choose
im plies collect iv e r esponsibilit y and goes t hr ough t he
logic of solidarit y, j ust ice and hum an dignit y. The fut ure
of Nu r sin g an d h ealt h w ill depen d on ou r collect iv e
and polit ical choices.
Nursing in the era of globalisation… Silva AL. Rev Lat ino- am Enferm agem 2008 j ulho- agost o; 16( 4) : 787- 90
790
REFERENCES
1 . San t os BS. Gl ob al i zação: f at al i d ad e ou u t op i a? Por t o: Af r on t am en t o; 2 0 0 1 .
2 . Fer r ei r a JMC. Tr a b a l h o e si n d i ca l i sm o n o co n t ex t o d a g l o b a l i z a ç ã o . I n : S c h e r e r - W a r r e n I , Fe r r e i r a JM C. Transform ações sociais e dilem as da globalização: um diálogo Br asil/ Por t u gal. São Pau lo: Cor t ez; 2 0 0 2 . p. 2 1 1 - 4 1 . 3 . Assm an n SJ. Glob alização com o f at o e com o id eolog ia. Rev Polít ica e Cu lt u r a 1 9 9 8 ; 1 ( 1 ) : 2 7 - 3 8 .
4. World Bank. Hum an w orld developm ent report 2000/ 2001. At t ack ing pover t y : oppor t unit y, em pow er m ent , and secur it y. Washingt on ( DC) : Wor ld Bank ; 2001.
5. Wor ld Healt h Or ganizat ion. Wor ld healt h r epor t . Making a differ ence. Genev a: WHO; 1 9 9 9 .
6 . List er G. Global h ealt h an d dev elopm en t : t h e im pact of
globalisat ion on t he healt h of poor people. Cam br idge ( UK) : The College of Healt h; 2 0 0 0 .
7 . Sen A. Key n ot e addr ess t o t h e Wor ld Healt h Assem bly. Gen ev a: WHO; 1 9 9 9 .
8. Or ganização Mundial da Saúde. Confer ência int er nacional s o b r e c u i d a d o s p r i m á r i o s d e s a ú d e . A l m a - A t a , URS S . Or ganização Mundial da Saúde, 1 9 7 8 . Disponív el em w w w . opas. or g. br / colet iva/ u ploadAr q/ Alm a- At a. pdf.
9 . Silv a AL. Pós- d ou t or ad o: d esaf ios e p er sp ect iv as. Rev Tex t o Con t ex t o En f er m 2 0 0 2 ; 1 1 ( 1 ) : 7 7 - 8 3 .
10. Mar ziale MHP, Mendes I AC. O inv est im ent o em pesquisa na área de saúde: t erm os de referência para o desenvolvim ent o cient ífico e t ecnológico brasileiro. Rev Lat ino- am Enferm agem 2 0 0 6 ; 1 4 ( 2 ) : 1 4 9 - 5 0 .
11. Silv a AL. A pesquisa com o pr át ica de cuidado. I n: Silv a AL, Ram os TRO, Lago MCS, or ganizador as. Falas de gêner o. Flor ian óp olis: Mu lh er es; 1 9 9 9 . p . 1 0 5 - 1 8 .
Recebido em : 3.9.2007 Aprovado em : 15.6.2008
Rev Lat ino- am Enferm agem 2008 j ulho- agost o; 16( 4) : 787- 90 w w w .eer p.usp.br / r lae Nursing in the era of globalisation…
