Global Health Rights, Sanitation, and Nursing's Role in MDGs

Introduction

Scholarly resources — including books, peer-reviewed journal articles, and reputable websites — are used throughout this paper to support the positions taken. Three questions are addressed: what basic types of healthcare everyone should have access to and why; a focused examination of one risk factor that impacts infectious disease; and an account of how nurses can contribute to one or more of the UN Millennium Development Goals (MDGs) for global health. While being overly generous about what people are entitled to, or about the full depth of what nurses can realistically accomplish, carries its own risks, it would be equally unwise to suggest that neither question is worthy of serious consideration.

The first question asks what types and forms of healthcare should be a guaranteed right for all people regardless of race, gender, class, or background. Before answering, several complicating factors must be acknowledged. The healthcare systems of many countries are in disarray due to entrenched governmental corruption or deeply ingrained public habits. Some governments — led by figures indifferent to the well-being of their populations — prioritize their own interests over those of the people they govern. Even comparatively better-off countries such as India and many parts of the Middle East contend with contaminated drinking water and inadequate sanitation infrastructure such as functioning toilets and waste management systems (Heijnen, Rosa, Fuller, Eisenberg & Clasen, 2014).

Healthcare as a Right

Another significant complicating factor is human behavior as a driver of health problems. This is by no means unique to developing nations. A considerable share of the diseases that burden people in the United States result from poor lifestyle choices that accumulate over years or decades. The problem is compounded by a social environment in which unhealthy foods are far more widely available and affordable than nutritious alternatives, and where health education for vulnerable populations is inconsistent at best. Even when education exists, caregivers are often unwilling to apply it. At the same time, genetics plays a role, and some individuals become ill despite making genuine efforts to maintain their health (Collins, Ryan & Truby, 2014).

The situation is further complicated by a healthcare system that grows more expensive each year — both in direct out-of-pocket costs and in the insurance premiums required to offset those costs. While the uninsured population in the United States represents a minority, it still numbers in the millions, and the financial devastation — including bankruptcies and preventable deaths — attributable in whole or in part to lack of healthcare access remains a serious concern (Zhou, Remsburg, Caufield & Itote, 2012). Yet those who argue that non-socialized healthcare countries should simply "spend more" must also reckon with the fact that transfer payments already constitute a substantial portion of the U.S. federal budget. Social Security, Medicare, and Medicaid alone account for more than half of the standard federal budget, and the growing number of people reaching or already at retirement age will place even greater financial pressure on these programs (Gamkhar & Pickerill, 2011).

With all of that acknowledged, there should nonetheless be a minimum standard of care that all people have the right to access at little or no cost. People with healthcare plans are generally able to receive preventive services — physicals, screenings, and checkups — at no additional cost. Such care should be subsidized or low-cost (ideally both) for those who cannot afford it due to limited income or lack of insurance. There should also be a strong emphasis on educating people how to prevent or reverse health disorders before they become acute, as this approach has already produced meaningful gains in the fight against obesity in many communities. Treating only those who are already sick is a reactive strategy; prevention will yield far better outcomes over time (Schimmel, 2013).

For this framework to function, it must be acknowledged that basic and necessary care can and should be provided through whatever means are available — without bankrupting the state or its taxpayers. However, patients also carry a share of the responsibility. Government programs are funded by taxpayers, and those receiving benefits are often not contributing proportionately to the tax base. Both sides of this equation carry ethical obligations. The patient has a right to access affordable, quality care, but also bears a responsibility not to engage in self-destructive behavior that is both preventable and costly to others. For example, while the Affordable Care Act eliminated waiting periods for pre-existing conditions, part of the original rationale for those waiting periods — however imperfectly applied — was that some people who could afford insurance chose not to purchase it until they urgently needed care. That is roughly analogous to buying homeowner's insurance while one's house is already on fire: it is unfair to those who pay premiums consistently, since the system depends on healthy participants offsetting the costs of sick ones. The goal is not to withhold care from anyone but rather to foster accountability and informed decision-making on all sides (Schimmel, 2013).

Among the many factors that contribute to the spread of infectious disease, cleanliness and sanitation stand out as particularly significant. As noted above, many parts of the world lack reliable running water, functioning toilets, and other basic sanitation infrastructure. This absence directly facilitates the spread of disease and contributes to poor dental and general health outcomes. What makes this situation especially troubling is that the affected populations are largely powerless to change it, as their governments are either unwilling or unable to act. Yet even wealthy, developed nations such as the United States and China have documented sanitation-related disease problems (Carlton, Liang, McDowell, Huazhong, Wei & Remais, 2012). The Tampa Bay Buccaneers NFL franchise, for instance, experienced a significant outbreak of drug-resistant staph infections (MRSA) despite having access to well-funded medical personnel and facilities. Three players — Carl Nicks, Lawrence Tynes, and Johnathan Banks — all contracted some form of staph infection within a two-to-three-month window (Volin, 2013).

This illustrates that many organizations and governments — whether due to negligence, insufficient resources, or simple inattention — fail to prevent infectious disease through basic cleanliness and sterilization practices. In poorer nations, the international community, including the United Nations and related organizations, should assist in upgrading and repairing sanitation infrastructure. Rather than funneling cash to corrupt or authoritarian regimes where it can be misappropriated, such efforts should be conducted under close supervision, with extensive training provided to local healthcare personnel and sanitation workers to build lasting standards that benefit entire communities (Clasen, Pruss-Ustun, Mathers, Cumming, Cairncross & Colford, 2014).

Within domestic healthcare settings, sterilization and cleanliness protocols must be reinforced continuously. This does not mean advocating for excessive germophobia, but it does mean that professionals who deviate from established hygiene standards should be addressed directly. For example, a case involving a healthcare worker who declined to follow standard pre-surgical scrub procedures on religious grounds illustrates the tension between individual beliefs and patient safety. While religious and cultural beliefs deserve respect in virtually all circumstances, patient safety cannot be compromised in a surgical setting. If a practitioner is unwilling to follow sterilization protocols before entering an operating room, they should not practice in that environment. Standards should always be reviewed to ensure they are reasonable and ethical — but any practice that compromises patient safety and can be reasonably prevented must be addressed without exception (Clasen, Pruss-Ustun, Mathers, Cumming, Cairncross & Colford, 2014).

For the general public, hygiene expectations need not be as stringent as in medical settings, but basic daily habits — showering regularly, washing hands after using the bathroom, and keeping food out of bathrooms — all contribute meaningfully to disease prevention. Another critically important public health measure is combating misinformation about immunizations. There is no credible evidence that vaccines cause autism, and the measles outbreaks that have occurred in recent years are a direct consequence of vaccine hesitancy driven by misinformation. The benefits of immunization against measles, mumps, rubella, tetanus, whooping cough, and other preventable diseases clearly outweigh the known risks. If vaccination rates continue to decline, diseases such as polio may re-emerge (Clasen, Pruss-Ustun, Mathers, Cumming, Cairncross & Colford, 2014).

The Millennium Development Goals, as established by the United Nations at the Millennium Summit in 2000, consist of eight goals:

1. Eradicate Extreme Hunger and Poverty
2. Achieve Universal Primary Education
3. Promote Gender Equality and Empower Women
4. Reduce Child Mortality
5. Improve Maternal Health
6. Combat HIV/AIDS, Malaria, and Other Diseases
7. Ensure Environmental Sustainability
8. Develop a Global Partnership for Development (UNMP, 2015)

Infectious Disease and Sanitation

In terms of how nurses can personally contribute to these goals, the answers are fairly clear for most — though some important limitations must be acknowledged. Combating HIV/AIDS and malaria, for example, is largely beyond the direct control of individual nurses except through education about risk behaviors and prevention practices, and this applies more to HIV/AIDS than to malaria. Malaria remains one of the deadliest diseases in human history by total fatalities, and the conditions that sustain it — infected mosquito populations and inadequate sanitation across large parts of the world — are not things a nurse can meaningfully alter alone. Until global sanitation standards are substantially improved, malaria will remain endemic in many regions, as it has for decades ("Malaria the Biggest Killer," 1979).

Similarly, developing a global partnership for development, eliminating hunger and poverty, and achieving universal primary education are goals that fall outside the practical scope of nursing. Nurses can, however, contribute to gender equality by treating male and female patients with equal care and respect, even when the governments or medical systems around them do not. Given that the nursing profession is predominantly female, advocating for equitable treatment of women in healthcare may come naturally to many nurses. It is worth noting, however, that some contemporary perspectives argue for a less gender-specific or more gender-neutral framing of nursing as a profession. The optimal outcome would be a profession that provides equal, gender-appropriate care to all patients regardless of the practitioner's gender (Hollup, 2014).

Child mortality presents a more nuanced picture. Many of the factors driving high child mortality rates globally are well beyond what nurses can address directly. That said, prompt and skilled nursing care in medical settings can meaningfully reduce deaths from disease and other medical complications. One way to assess and improve nursing performance in pediatric contexts is through the use of validated measurement tools such as the Nursing Manpower Use Score (NEMS) and the Therapeutic Intervention Scoring System (TISS-28), both of which are used in pediatric intensive care units (PICUs). A study conducted in Brazil applied both measures simultaneously over two years, spanning more than 800 patients and nearly 8,000 patient events, and found strong correlations between the two instruments for the same cases — validating their use as complementary tools for assessing nursing workload and care quality (Travi-Canabarro, Stochero-Velozo, Rosaria-Eidt, Pedro-Piva & Ramos-Garcia, 2013). Maternal health, another MDG, is closely linked to child mortality, as a healthy mother generally contributes to better outcomes for her child.

The final goal not yet discussed in detail is environmental sustainability. While this may appear to be at the periphery of nursing's role, nurses can and should contribute to sustainability efforts within healthcare settings. This includes disposing of needles and other sharps properly, recycling and reusing materials when it is safe and ethical to do so, and avoiding unnecessary waste. Physicians are unlikely to manage these tasks given their other responsibilities, making nurses central to any practical sustainability effort in clinical environments (Higuchi, Downey, Davies, Bajnok & Waggott, 2013).

This is especially relevant in nationalized or socialized healthcare systems, where financial and material resources are finite and often under strain. In such systems, nurses must use, allocate, and manage resources responsibly. While no reasonable person would suggest reusing needles or contaminated materials, wasteful or negligent practices of any kind are both unethical and, in many cases, illegal. Stockpiling supplies to the point that perishable items expire and go to waste is never appropriate — particularly when those supplies are in short supply elsewhere. The right balance is to maintain enough supplies to meet patient needs without hoarding or squandering what others may need (Higuchi, Downey, Davies, Bajnok & Waggott, 2013).

In the end, all three questions addressed here have reasonably clear answers at a conceptual level. Implementing those answers, however, is considerably more difficult — constrained by those who hold power, the finite resources available, and the persistence of misinformation and political obstacles. People should unquestionably have access to affordable, quality healthcare, but "free at the point of care" does not mean costless — someone pays for it. Upgrading sanitation infrastructure in impoverished countries is clearly necessary, but doing so requires substantial resources and the cooperation of local authorities who may not be willing partners. And while the Millennium Development Goals articulate an inspiring vision for global health and human development, the gap between stating such goals and achieving them remains vast. Progress is possible, but the obstacles are real and must be taken seriously by anyone genuinely committed to addressing them.

Carlton, E.J., Liang, S., McDowell, J.Z., Huazhong, L., Wei, L., & Remais, J.V. (2012). Regional disparities in the burden of disease attributable to unsafe water and poor sanitation in China. Bulletin of the World Health Organization, 90(8), 578–587. doi:10.2471/BLT.11.098343

Clasen, T., Pruss-Ustun, A., Mathers, C.D., Cumming, O., Cairncross, S., & Colford, J.M. (2014). Estimating the impact of unsafe water, sanitation and hygiene on the global burden of disease: evolving and alternative methods. Tropical Medicine & International Health, 19(8), 884–893. doi:10.1111/tmi.12330

Conclusion

Zhou, G., Remsburg, R., Caufield, C., & Itote, C. (2012). [Healthcare access and financial strain reference — full details as in source].