What is Global Health?

Global health’ is coming of age, at least as measured by the increasing number of

academic centres, especially in North America, which use this title to describe their
interests . Most global health centres are in high-income countries although several
have strong links with low- and middle-income countries. A task force is establishing
a mechanism to coordinate European Academic Global Health initiatives through
ASPER. Two recent papers raise important issues about the meaning and scope of
global health and highlight, yet again, the need for a common definition of global
health which is short, sharp and widely accepted, including by the public (4).
Koplan et al. from the Consortium of Universities for Global Health Executive Board
point out that without an accepted definition of global health, it will be difficult to
agree on what global health is trying to achieve and how progress will be made and
monitored (2). This is particularly important given the recent global crises – climate
change, economic, food and energy crises – that make global health efforts even more
challenging (5).
Koplan and colleagues propose a definition of global health which they hope will
receive wide acceptance and thus encourage global health efforts. They distinguish
between global health, international health and public health; tropical medicine has
close connections with international health (1). However, there is widespread
confusion and overlap among the three terms.

Emerging Global Health Issues: A Nurse’s Role

^ m d 
 

Cole Edmonson, DNP, RN, FACHE, NEA-BC, FAAN

Cindy McCarthy, DNP, MBA, MHA, RN, NEA-BC, CEN
Sylvia Trent-Adams, PhD, RN, FAAN
Cindy McCain
June Marshall, DNP, RN, NEA-BC

Abstract

Global health issues (GHIs) require global cooperation in response, planning, prevention,
preparedness, and care that reflects health equity issues among nations. These issues require complex
interprofessional and interagency cooperation and solutions that involve governments, non-profits,
and many times include private companies and foundations. More than ever, the response to GHIs
requires a broader understanding of how connected we are in today’s world. This article considers
response to issues of emerging infectious diseases, human trafficking, maternal-newborn health;
preparedness for health inequities within a framework of social justice, equity; and mal-distribution of
health workers globally. We define and describe emerging global health issues from a nursing
perspective and offer a call to action for nurses to increase awareness as global leaders.

Citation: Edmonson, C., McCarthy, C., Trent-Adams, S., McCain, C., Marshall, J., (January 31, 2017)
"Emerging Global Health Issues: A Nurse’s Role" OJIN: The Online Journal of Issues in Nursing Vol. 22,
No. 1, Manuscript 2.

DOI: 10.3912/OJIN.Vol22No01Man02

Key Words: global health issues, nursing, emerging infectious disease, maternal – newborn health,
social justice, equity, human trafficking

Global health issues transcend national boundaries. Global health issues (GHIs) transcend national

boundaries (Koplan et al., 2009). These issues require global cooperation in response, planning,
prevention, preparedness, and care that reflects health equity issues among nations. GHIs require
complex interprofessional and interagency cooperation and solutions that involve governments, non-
profits, and many times, include private companies and foundations. More than ever, GHIs force a
broader understanding of how connected we are in today’s world.

...[the] idea of boundaries may provide a false sense of security and detachment from issues

occurring in other parts of the world. The economic crash in the late 2000s and epidemics that

cross countries in a matter of hours and days are all fueled by greater connections, information
technology, international travel, and migration patterns. One can see how quickly a crisis or issue in
one country can affect and spread to other countries through porous borders and technology venues.
No longer are borders defined by traditional lines or maps as they once were. In fact, this idea of
boundaries may provide a false sense of security and detachment from issues occurring in other parts
of the world.

A review of the literature of global health issues uncovered numerous concerns, from global warming
and terrorism to emerging infectious diseases. This article focuses on one infrastructure issue that
continued to surface and impacted each of the additional GHIs we selected: emerging infectious
diseases, human trafficking, and maternal-newborn health. Nurses can potentially impact each of
these three prominent concerns. However, the mal-distribution of health workers around the globe, an
infrastructure issue, impacts the effort to prevent these emerging GHIs and/or care for patients,
families, and communities affected by, or at risk from them. It is also clear that two key concepts
must be addressed in relation to GHIs, social justice and equity and the existence of health disparities
as a result of multiple influencing factors.
 Of great concern in GHIs is the maldistribution of the healthcare work force in terms of geography,

disease, infrastructure and resources.  GHIs occur in numerous ways and are influenced by a

multitude of factors that can best be impacted by the nursing community with awareness building,
focused education, nurse activation, and infrastructure support, with the nurse acting as a sentinel. Of
great concern in GHIs is the maldistribution of the healthcare work force in terms of geography,
disease, infrastructure and resources. The ability to impact GHIs depends, in part, on the presence of
appropriate resources of all types, including human. In the next section, we will define and briefly
describe the three emerging global health issues to provide context for the reader

Definitions of Key Global Health Issues

Infectious Diseases 

Infectious diseases... have been defined as "emerging." These diseases respect no national

boundaries, with increased incidence in humans in the past 2 decades or threat of increase in the near
future, have been defined as "emerging."  boundaries. They include new infections resulting from
changes to or evolution of existing organisms; known infections spreading to new geographic areas or
populations; previously unrecognized infections appearing in areas undergoing ecologic
transformation; and old infections reemerging as a result of antimicrobial resistance in known agents
or breakdowns in public health measures (Morse, 1995).

Human Trafficking
Human trafficking is defined as all acts involved in recruiting, harboring, transporting, providing, or
obtaining a person for compelled service or commercial sex acts through the use of force, fraud, or
coercion (DeBaca & Sigmon, 2014). This global health issue, although not new, has recently garnered
increased concern.

Maternal-Newborn Health
Maternal mortality is defined as the death of a woman while pregnant, or within 42 days of
termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause
related to or aggravated by the pregnancy or its management (i.e., from direct or indirect obstetric
death), but not from accidental or incidental causes (Morse, 2014). The major causes of death in
newborns include complications of premature birth and intra-partum related complications (previously
labeled as birth asphyxia and sepsis) (Bhutta & Black, 2013).

Nurses and Health Inequities

 Many defined roles and responsibilities for public health nurses also apply to nurses in other

specialties and settings.  The public health nurse roles and responsibilities to eliminate health

inequalities and achieve equity are delineated in a Position Paper (Association of Public Health Nurses,
2015) that focuses on the importance of awareness of self and others; trust as a foundation of every
human relationship; and humility in acknowledging what is not known about diverse cultures and
populations. Many defined roles and responsibilities for public health nurses also apply to nurses in
other specialties and settings. Additionally, nurses must recognize and understand the impact of social
determinants of health on population outcomes, including genetics; social and physical environments;
socioeconomic status; biologic and behavioral responses; access to care; availability of food and
transportation; and others. Poverty, inequality, and social determinants of health not only contribute
to global health issues but can also adversely impact morbidity, mortality, and health outcomes
(Quinn & Kumar, 2014).

Nurses in roles across health system and community settings are well positioned to assess individuals,
communities, and populations; advocate for justice and equality; and partner with legislators and
inter-professional leaders to identify, implement, and evaluate a “strengths-based approach” that
engages communities addressing local, national and global health issues. However, many countries
lack sufficient healthcare workers, including nurses, to address GHIs.

Maldistribution of the Healthcare Workforce

While a growing shortage of healthcare workers is predicted over time, there is also a parallel

estimated increase in the global population. In 2013, the World Health Organization (WHO)

estimated that the world will be short 12.9 million health-care workers by 2035; today, that figure
stands at 7.2 million (World Health Organization, 2013). As recently as 2009, two reports estimated
the global shortage to be more than four million health workers (Joint Learning Initiative,
2004; Salafsy, Glasser & Ha, 2005; WHO, 2006). While a growing shortage of healthcare workers is
predicted over time, there is also a parallel estimated increase in the global population.

As of July 2015, the world population of 7.3 billion was projected to reach 8.5 billion by 2030 and 9.7
billion by 2050 (United Nations, 2015). Most of the projected increase in the world population is
expected to occur in Africa or other countries with already large populations. During 2015-2050, half
of the world population growth is expected to be concentrated in nine countries: India, Nigeria,
Pakistan, Democratic Republic of the Congo, Ethiopia, United Republic of Tanzania, United States of
America (U.S.), Indonesia, and Uganda, listed according to the size of their contribution to the total
growth (Greysen, Chen, & Mullan, 2011).

The United States and Canada, which comprise 14 percent of the world population, bear
approximately 10 percent of the world disease burden, have 37 percent of the global health workforce
and spend about 50 percent of the world financial resources for health. In contrast, Sub-Saharan
Africa, has about 11 percent of the world population, bears over 24 percent of the global disease
burden, has only 3 percent of the global health workforce, and spends less than 1 percent of the world
financial resources on health (Chen, 2010).

The number of healthcare workers is only one of many factors impacting access to care on a global

scale. The widening gap between supply and demand of healthcare workers indicates the need

for an urgent response. Closing the gap to improve access to care is not as simple as producing more
healthcare workers. Many factors impact the balance of demand and the supply of timely, appropriate
care. The number of healthcare workers is only one of many factors impacting access to care on a
global scale.

Allocation of adequate financial resources and infrastructure are longstanding global health issues.
Human resources for health have been significantly underfunded, which contributes to maldistribution
of healthcare workers (Chen et al., 2004). Often described as an unequal ratio of health workers for
the population, maldistribution simply means there are a misalignment of the number and/or skillsets
of healthcare workers in comparison to the demand for services within the specific population or
geographic area.

In many countries, health worker shortages are exacerbated by severe maldistribution... most

professionals seek urban-based, middle-class professional work and personal lives. Maldistribution is

a major challenge to improving access to care for underserved populations, as well as in addressing
workforce shortages and clinical competencies. In many countries, health worker shortages are
exacerbated by severe maldistribution (Chen et. al., 2004). This is not a new phenomenon; most
professionals seek urban-based, middle-class professional work and personal lives.

Geography is a major driver of access to healthcare, especially in the global setting. In most areas
across the world, urban-rural disparities exist. Rural areas tend to have fewer health resources and
lower staffing across clinical professions. For individuals living in rural areas, it is often difficult to
access healthcare services due to transportation, terrain, distance to providers, and inadequate
infrastructure (Salafsy et al., 2005). It is common for individuals who live in rural areas to delay care
until their conditions are severe and require more intensive treatment. This situation often results in
more expensive care and poorer clinical outcomes.

Healthcare workers are not easily attracted to many rural areas where there are limited options to
work. They may perceive negative lifestyle differences when compared to urban and suburban
options. Salaries for health workers tend to be lower in rural areas, but these individuals may work
longer hours due to the limited number of providers. In the United States, the cost of health
professionals has significantly increased. For the past fifty years, the cost of medical education has
increased at a rate unsurpassed in history (Chen, 2010). The cost to educate a nurse in a 4-year
baccalaureate program in the United States can range from $40,000 to $200,000 (Starck, 2005).
Healthcare providers in many areas around the world seek positions in areas that enable them to
practice their chosen profession, meet living expenses, and obtain a certain standard of living.

Lack of an adequate supply and global maldistribution of healthcare resources has created significant
gaps in access for many populations. This poses a major social justice issue. In general, social justice
is the view that everyone deserves equal economic, political, and social rights and opportunities. This
concept is an essential belief of the nursing profession (ANA, 2015). Ideally, nurses should strive to
assure that everyone who needs care can access the services they need. Access to equal care and
treatment, however, remains an elusive goal. Social justice is more than treating people fairly; it
involves rejection of the status quo for the greater good.

The connection between health outcomes and social determinants of health reinforces the

importance for nurses to engage collectively on a global level to positively impact population health

outcomes. As a principle, social justice requires the nursing profession to question the system of

care, models of delivery, and the balance of resources. There is growing concern that a broad range of
social, economic, and environmental factors shape individuals’ opportunities and barriers to engage in
healthy behaviors. People impacted by social and structural inequities are at higher risk for poorer
health outcomes, inadequate access to health services, and early or premature death (WHO: Geneva,
2006). The connection between health outcomes and social determinants of health reinforces the
importance for nurses to engage collectively on a global level to positively impact population health
outcomes.

The factors above contribute to emerging GHIs at the infrastructure level in the form of resource
allocation and relative distribution to burden areas. The maldistribution impacts all GHIs, including the
three areas of focus in this article. In the next section, we will consider in depth three GHIs: emerging
infectious diseases, human trafficking, and maternal-newborn health.

Emerging Infectious Diseases

Findings from the [Ebola epidemic] data analysis pointed to lack of public awareness regarding

nurses’ critical roles and the gap in system preparedness for such global health events.  Throughout

history, nurses have played key roles in recognizing and responding to emerging disease threats
across the care continuum. Hall and Kashin used both document and in-depth content analyses
methodologies to examine media portrayals of nurses’ roles during the western Africa 2014-2015
Ebola epidemic (Hall & Kashin, 2016). Findings from the data analysis pointed to lack of public
awareness regarding nurses’ critical roles and the gap in system preparedness for such global health
events. In 2011, the International Council of Nurses (ICN, 2011) issued a position statement related
to “reducing travel-related communicable disease transmission" (p. 1). In that position statement, the
ICN supports the position that nurses are “uniquely positioned to assist governments and other
agencies to implement and evaluate” communicable disease outbreak prevention and response (p. 1).
Additionally, nurses’ have valuable expertise, competencies, and grassroots perspectives to impact the
prevention, spread, and management of infectious disease outbreaks. They are positioned for
important roles in care delivery, education, leadership, and policy making to influence population
health outcomes.

The American Nurses Association (ANA) website contains a page entitled “Emerging Infectious
Diseases” (n.d.) where definitions, information about emergency preparedness, and an annotated list
of resources are readily accessible and provide valuable information for nurses in all roles and
settings. A list of these resources, and others, is included in the Table. The ANA, the Centers for
Disease Control and Prevention (CDC), and the Association for Professionals in Infection Prevention
and Epidemiology (APIC) all provide useful, evidence-based information, tools, and resources to guide
nurses to plan, prevent, and manage emerging infectious diseases.

Table. Emerging Infectious Disease Resource for Nurses

Source Content Summary Website Address

American Academy 1. Policy briefs and recommendations http://www.aannet.org/policy-
of Nursing for combating emerging infectious advocacy/
diseases.
emerging-and-infectious-diseases
American Nurses 1. ANA/APIC Resource Center – http://www.nursingworld.org/
Association (ANA) information regarding healthcare MainMenuCategories/
associated infections, personal
WorkplaceSafety/
protective equipment, emerging
Healthy-Work-Environment/ANA-
diseases, and hand hygiene.
2. “Emerging Infectious Diseases” APIC
section includes information on
emergency preparedness, access to http://www.nursingworld.org/
additional resources, and MainMenuCategories/
“understanding emerging and re- WorkplaceSafety/
emerging infectious diseases.”
Healthy-Work-Environment/ANA-
APIC/
Emerging-Diseases
Association for 1. Main APIC website and home page http://www.apic.org/
Professionals in includes a search engine with a
number of relevant “emerging
Infection Prevention
diseases” resources are located.
and Epidemiology
2. “Emergency Preparedness” section
(APIC) includes resources on bioterrorism
and a number of resources related
to preparedness and response to http://www.apic.org/Professional-
pandemics (influenza and others). Practice/Emergency-Preparedness
3. APIC Implementation Guides –
evidence-based strategies for
surveillance and elimination of
infection.
 4. Monthly “Consumer Alerts” with
information related to infectious
diseases targeted at the public.
5. “Infection Prevention and You” for
Healthcare Professionals – “Bugs
and Outbreaks” – information http://www.apic.org/Professional-
pertaining to bacteria, viruses, and Practice/Implementation-guides
foodborne outbreaks in the news
media.
http://www.apic.org/For-
Consumers/Monthly-alerts-for-
consumers

http://professionals.site.apic.org/
bugs-and-outbreaks/
Centers for Disease 1. Access to Emerging Infectious http://wwwnc.cdc.gov/eid
Control and Diseases journal.
2. Emergency Preparedness and
Prevention (CDC) https://emergency.cdc.gov/
Response –Recent Outbreaks and
Incidents, current outbreak list and recentincidents/
resources, and additional content
about specific disease outbreaks.

In 2011, the CDC published “Framework for Preventing Infectious Diseases” to serve as “a roadmap
for improving our ability to prevent known infectious diseases and to recognize and control rare,
highly dangerous, and newly emerging threats, through a strengthened, adaptable, and multi-purpose
U.S. public health system” (CDC, 2011, p.iii). At that time, the CDC addressed concerns such the 2009
H1N1 influenza virus; resurgence of diseases (e.g. dengue fever, pertussis) in new locations;
outbreaks of foodborne illnesses (e.g., Salmonella);  and the appearance of a highly resistant strain of
gonorrhea.

Considerable experience gained during the avian influenza outbreak informed the major roles of

nurses as they managed the response to the SARS outbreak. Ho and Parker (2006) reported

lessons learned about nurse roles from public health nurses’ experiences in Hong Kong responding to
the avian influenza outbreak of 1997 and subsequent influence and management of the Severe Acute
Respiratory Syndrome (SARS) outbreak in 2003. These public health nurses traced contacts; provided
education to the public regarding disease signs and symptoms; sought consent; obtained samples;
took health histories; participated in investigation, monitoring, and surveillance; and served on
research teams in related case control studies. Considerable experience gained during the avian
influenza outbreak informed the major roles of nurses as they managed the response to the SARS
outbreak.

Devereaux (2015) conducted an evolutionary concept analysis on pandemic influenza that highlighted
the need for efficient responses and further investigation into implications for the nursing profession.
The 49 papers included in the final sample were from public health, medicine, law, bioethics, and
healthcare policy literature. Devereaux made the assumption that no articles in the sample were tied
specifically to nursing because nurses work on the front lines as public health professionals to address
these influenza pandemics and develop related approaches to preparedness. The review brought to
light the defining attributes that differentiate pandemic influenza from other infectious disease
outbreaks, including “original viral structure, increased human susceptibility, younger vulnerable
populations, and unpredictable timeframes” (p. 1788). Devereaux also delineated how findings from
this concept analysis can be used to influence policy, practice, research, and education. She stressed
the importance of nurse involvement in pandemic preparedness, the critical need for sufficient staff
resources and deploying skilled, competent nurses with capability to meet population care needs.

Nurses in all settings and roles are key contributors to emerging disease prevention, response, and
management. Nurses in roles at micro-, macro-, or meso-system levels bring important expertise, and
perspectives to healthcare teams to plan, implement, and evaluate response to emerging disease
outbreaks and epidemics. Nurse understanding of and expertise regarding care delivery models,
complex systems, resources, infection prevention and control principles, and biopsychosocial human
needs make them valuable assets as leaders and members of interprofessional healthcare,
community, and legislative advocacy preparedness.

Human Trafficking

... it is important to see HT as a global public health problem in need of focused identification and

responsive interventions. Human trafficking (HT) is perceived as a form of modern day slavery.

HT is also increasingly recognized as a global public health problem (McCain, 2016b). Guidance for
healthcare providers has emerged in the literature, as well as calls for development of new education
and training programs for nurses. Given the scope of this problem, it is important to see HT as a
global public health problem in need of focused identification and responsive interventions (Isaac,
Solak, & Giardino, 2011). In this section, we provide background about human trafficking and discuss
efforts related to nurses and advocacy.

Background. A new global report on trafficking released in 2014 noted that the two most common
forms of trafficking are sexual exploitation (53%) and forced labor (40%) (Neupane & Kallestrup,
2014). HT takes the form of economic, physical, and sexual exploitation of persons, thus reducing its
victims to mere products for commerce.

Human trafficking is the second largest, and fastest growing, organized crime trade in the world. It
has surpassed illegal arms trade, and is expected to surpass the illegal sale of drugs in the next few
years (Peters, 2013). The International Labor Organization reports that financial gains of this well-
organized and highly secretive business are estimated at up to $44 billion U.S. dollars annually
(Peters, 2013). Studies show that the United States is one of the primary destinations for foreign
trafficked victims, mainly because of the high profits available to traffickers.
 An estimated 800,000 people are trafficked across international borders every year. Of these,

50,000 are trafficked into the United States, meaning there are twice as many people enslaved today
as during the African slave trade (Dovydaitis, 2010). This number does not include American citizens
trafficked to foreign nations. The estimate is that 100,000 to 200,000 American minors are currently
exploited in the United States within the sex industry (Allen, 2010). Although difficult to quantify
because of its clandestine nature, 12.3 million people in the world are estimated to be living as human
trafficking victims at any given time (Isaac et al., 2011). Nurses who are educated about risk factors
and clinical manifestations of HT, and who can provide efficient and compassionate assistance to
patients, have the potential to play an important role to address this problem (Alpert et al., 2014).

Amidei (2010) has described advocacy as seeing a need and finding a way to address it. An advocate
is defined as one that pleads, defends, or supports a cause or interest of another (Tomajin, 2012).
Nurses provide 24-hour continuity of care and close surveillance, and are regarded as ‘gatekeepers’
for patients (Choi, 2015). A major role of the nurse in regards to HT victims is that of advocacy.

Nurses and HT advocacy. Trafficked individuals are often subjected to physical, sexual, and
psychological abuse during their exploitation. An estimated 28-50% of these individuals access
healthcare services while being trafficked (Golby, Tsuei, Zacharias, 2015). Because of the violent
nature of the business, HT victims are frequently left with life-threatening injuries. Emergency
department (ED) nurses are in a unique position as one of the few professionals likely to encounter
trafficked victims and can be the first to interact with victims. This poses an urgent and unique
opportunity for nurses to identify, support, and refer victims to appropriate agencies. Incorporating
relevant training for nurses and other healthcare providers is crucial.

Nurses have a potentially important, but currently largely unrealized role, in HT victim identification

and rescue... Nurses have a potentially important, but currently largely unrealized role, in HT

victim identification and rescue (Grace et al., 2014) thus appropriate skills and knowledge are
imperative. As frontline caregivers, nurses are often the bridge between victims and other service
providers and resources. In addition to identifying HT victims, healthcare providers need to be able to
ask the right questions and offer assistance. Many victims do not self-identify as trafficking victims,
but when asked the right questions, clearly fit the definition.

Despite lack of scientific data to support and fully appreciate the role of healthcare providers in
identifying and assisting victims of HT, we can still learn lessons from the research available, and
anecdotal reports from clinicians (Clayton, Krugman & Simon, 2013). In a survey of 159 service
providers across the United States, including nurses who work with victims and survivors of HT, the
lack of adequate training was identified as a key barrier to providing services (Clawson, Small, &
Myles, 2013).

Nurses face challenges to identify appropriate, well-designed education offered by qualified

individuals. As the incidence of HT increases locally and globally, so should learning opportunities and
resources to properly inform nurses. With global evidence showing ever-changing and complex health
trends, nursing competencies to appropriately address emerging issues come under scrutiny. The role
of nurses in clinical practice is dynamic and evolving; much more is asked of nurses in today’s practice
settings. Nurses have a duty and responsibility to seek necessary competency to support current
practice and to positively impact new challenges such as HT.

In a recent study that focused on the health sector response to HT victims (Konstantopoulos et. al.,
2013), it was proposed that local health systems take an expanded anti-trafficking role, in addition to
providing illness-related, episodic care for trafficking victims. This study highlighted the unmet need
and significant opportunity for local health systems to assume a more active role in anti-trafficking
work. Nurses and nurse educators are important to the development of social responsibility. They
must prepare to fully develop strengths of the nursing profession in the context of an increasingly
globally connected world. Nurses who are active in professional nursing organizations and/or other
medical societies should advocate for the official recognition of HT as an important public health issue.
Such efforts lay groundwork for those in the health sector to increasingly participate in anti-trafficking
policymaking at local and national levels to ensure that the public health perspective is incorporated
into future anti-trafficking initiatives (Konstantopoulos et al., 2013).

Frontline nurses are and will be leaders in the recognition of and intervention for HT victims. The

McCain Institute for International Leadership at Arizona State University (2016) is one group working
diligently to counter human trafficking. Mrs. Cindy McCain (coauthor 4) chairs the Human Trafficking
Advisory Council at The McCain Institute. The institutional commitment to strengthen character-driven
global leadership is reflected in its efforts to support humanitarian action. The Institute recently
hosted a human trafficking conversation series event, “Building a Healthcare Response to Human
Trafficking.” This event highlighted the importance of participation by healthcare providers to address
human trafficking. Institute leaders are also working to help incorporate a human trafficking training
program into nursing school curricula (McCain Institute, 2016). One does not necessarily have to fill a
formal leadership role to be considered a leader, especially in cases related to global health issues
such as HT. Frontline nurses are and will be leaders in the recognition of and intervention for HT
victims.

The McCain Institute has sponsored research projects that have demonstrated that a very high
percentage (estimated 68% by the National Center for Missing and Exploited Children) of children in
contact with U.S. child welfare and foster care systems have likely been trafficked. (McCain, 2016).
According to McCain (2016) in testimony before the Senate Foreign Relations Committee, “Human
Trafficking is not just an international issue and we as a country need to address it in our own states
and communities. Once we protect the most vulnerable among us in our nation, we can become a
global leader in the fight to protect those that cannot protect themselves” (p. 4).

Public awareness is a first step in the fight against HT... The ideal person to initially examine an HT

victim is a forensic nurse, a nurse with Sexual Assault Nurse Examiner (SANE) certification, or an
emergency nurse with advanced training in evidence collection, preservation, and documentation
(Peters, 2013). Established SANE programs provide the best venue for SANE nurses to gain the trust
of victims, thus increasing the chance of rescue from their traffickers. Specially trained nurses are also
excellent resources to provide training and education to law enforcement and emergency medical
services (EMS) agencies and to increase awareness for local community groups, businesses, and civic
organizations. Public awareness is a first step in the fight against HT; the best defense against HT is a
knowledgeable, engaged, and acutely aware community.

Nurses can take a more active role in HT awareness by focusing on the training and education of other
healthcare professionals within the hospital and the community. An interprofessional approach is key
to address issues of HT through training programs, online education, and establishment of protocols.
Awareness campaigns and community education also improve victim identification. Finally, nurses can
support ongoing HT research in a vital effort to quantify the magnitude of the problem and make this
information available and understandable to communities, healthcare systems, and governmental
agencies.

Maternal Newborn Health

Maternal and newborn health issues are a global health priority.   Maternal and newborn

health issues are a global health priority. Maternal deaths arise from risks tied to pregnancy and
childbirth, in addition to poor quality healthcare. Maternal mortality is a serious international public
health issue. More women die from pregnancy-related causes in the United States than in any other
developed nation, and the maternal mortality rate is increasing over time (Advisory Board, 2016).
Every year over half a million women die of pregnancy-related causes worldwide, and in addition, an
estimated four million neonatal deaths occur (van den Broek & Graham, 2009). People-centered care
that recognizes the legitimate right to and expectations for equitable, high-quality, safe and respectful
care should be a global health priority at the heart of the movement to improve maternal and newborn
care (Hoope-Bender et al., 2014). The global health community should continue to fast-track progress
toward elimination of all preventable causes of maternal and newborn mortality.

What makes this issue more pressing and a worldwide focus is that these are preventable

deaths.  Leading causes of maternal deaths in the United States overlap with the main global

causes; hemorrhage, pregnancy-related hypertensive disorders and infection are among the top
causes of death in both the U.S. and the developing world (Bingham, Strauss & Coeytaux, 2011). The
largest numbers and highest rates of maternal, neonatal and child deaths are in the country of sub-
Saharan Africa and South Asia (Bhutta et.al., 2013). What makes this issue more pressing and a
worldwide focus is that these are preventable deaths. An ambitious but realistic global target is to
reduce maternal mortality ratios to less than 50% per 100,000 livebirths by 2035 (Bustreo et al.,
2013).

Maternal-newborn health issues require the nurse to consider not just one, but two or more patients,
when seeking to improve care and quality outcomes. This requires a focus on wellness care and
prevention as opposed to illness care. Nursing care provided during the birth process is critical but
nurses also have an impact in the antenatal setting. Recent research has established linkages of
reproductive health with maternal, perinatal, and early neonatal health outcomes (Bhutta, Lassi, Blanc
& Donnay, 2010). One goal associated with improving antenatal care is to emphasize the importance
of other healthcare needs, such as tetanus immunization, family planning, and prevention and
treatment of human immunodeficiency virus (HIV).

A key factor for successful education of nurses and other interprofessional team members is an
evidence based practice approach. The evidence based movement over a decade ago created a culture
for questioning and guiding the content of interventions. A similar shift of paradigm is needed today to
question and guide the quality of implementation strategies at both individual service and health
system levels (van den Broek & Graham, 2009).

Working with families and communities is necessary to focus on improving access to and use of quality
health programs that include prevention initiatives. One means to achieve this goal is to implement
strategies concentrated on education, provision of care, and health system strengthening. Nurses and
other healthcare professionals have knowledge, opportunity, and often political leverage. This can help
ensure, through advocacy or direct participation, that patients take preventive actions (Michael,
Nyong, & Corvalan, 2008).

Patients and families expect knowledgeable caregivers, and specialty certification can provide

reassurance about nurse competence. Nurses who specialize in the field of maternal newborn

health should be encouraged to achieve certification in this area. Certification in a nursing specialty
demonstrates a commitment to advancing one’s knowledge and skillset. It is official recognition of
achievement, expertise, and clinical judgment from the profession and requires continued learning and
skill development to maintain (American Nurses Credentialing Center, 2010). Some research has
indicated a link between certification and nurse knowledge, techniques, and judgement that may
affect patient safety (Niebuhr & Biel, 2007). Public awareness of the value of nurse certification is
increasing. Patients and families expect knowledgeable caregivers, and specialty certification can
provide reassurance about nurse competence.

Call to Action for Nurses as Global Leaders

Leadership begins when students embrace the meaning of ethical nursing practice and continues
throughout one’s career, as nurses make the links from individuals to populations and from the local
to the global context (Canadian Nurses Association, 2009). The first of eight essential nurse leader
competencies for 2020, established by the Canadian Nurses Association (2009), is a global perspective
or mindset regarding healthcare and professional nursing issues. Perhaps these essential
competencies should be considered as an exemplar to other economically advantaged countries.
 The role of the nurse leader has to expand beyond the walls of hospitals and other healthcare

settings if we are to successfully impact the fight against emerging GHIs.  Nurse leaders at all levels

are called upon to think and act differently in today’s ever changing healthcare environment. Each day
brings new and greater challenges that nurses must face head-on. Leaders must be strong,
innovative, financially savvy, and willing to take on increasingly difficult and complex situations.
Nurses must be willing to lead by example, set clear expectations, and require accountability. A leader
must also be visionary and forward thinking. Leaders provide vital support by supporting flexibility and
agility as employees respond to the constantly changing global healthcare market (Cianelli, Clipper,
Freeman, Goldstein & Wyatt, 2016). If we are to create and sustain change, it must come from the
nurse who is both a leader and a change agent.

The role of the nurse leader is key to help an organization prepare for and lead change. Nurse leaders
must model the role of change agents and lead by example in change implementation demonstrating
equanimity. An effective change agent is disciplined, thinks rationally with an open mind, and is
informed by evidence (Oulton, 2014). Evidence-based practice drives today’s healthcare environment,
and nursing practice in particular, and must be the framework for frontline nurses to begin prevention,
early recognition, intervention and implementation of practices and programs to address GHIs.
Support of nurse leaders for implementation of these practice innovations is crucial to establish an
environmental culture that adopts and values EBP (Clement-O’Brien, Polit & Fitzpatrick, 2011).
Administrative support is also critical to gain the trust of frontline nurses as they embark on a journey
of change that will positively impact GHIs they face in practice on a daily basis.

Being a global leader requires an understanding of the wider context; it means having a view greater

than the local perspective and realizing connections and relationships that exist globally. The role of

the nurse leader has to expand beyond the walls of hospitals and other healthcare settings if we are to
successfully impact the fight against emerging GHIs. Nurse leaders are also instrumental in facilitating
change within the community and should seek such opportunities. For example, by becoming a
member of a local board, the contribution of nurses and nursing is represented at community tables
and can positively impact change that reaches far beyond traditional healthcare delivery settings.

Global leadership in health requires vision, strategic thinking, credibility, and the ability to work with
and influence others. It also requires the leader to be a global citizen, or someone who works to make
the world a better place. A global citizen is aware of the wider world; respects and values diversity;
and is outraged by social injustice at any level (Oulton, 2014). Being a global leader requires an
understanding of the wider context; it means having a view greater than the local perspective and
realizing connections and relationships that exist globally. Global leaders who act as change agents
work to develop this enhanced global perspective in frontline nurses.
An interprofessional approach to GHIs provides a more united front and an increased chance of
success. Nurse leaders also have the opportunity to engage physicians, advanced practice nurses, and
other ancillary healthcare providers in a global level response. The more people are able to reach out
and impact the community, the louder the message delivered. Leaders must take responsibility to
filter knowledge of GHIs downward and upward within organizations. In response to any emerging
GHI, this bi-directional pathway is important to both heighten awareness and gain support at all
levels.

Leaders must take responsibility to filter knowledge of GHIs downward and upward within

organizations.  Although global health and its predecessor international health have been around

for centuries, improvements in travel and the rise of communicable diseases have made an integrated
global approach to health necessary (Hargarten, Martin, Hauswald & Hirshon, 2013). Creating a strong
united voice and developing global level leadership skills will ensure that nurses’ voices are heard in
strategies to lead initiatives for improved health.

Conclusion

Global health issues do not exist in a vacuum... Global health issues do not exist in a vacuum;

they are problems of high complexity that must be fully and comprehensively considered. Simple
solutions do not exit. These multidimensional problems require global collaboration, organization, and
resources, applied with a bold vision and true commitment. The lens of social justice may better frame
solutions required at micro-, meso-, and macro-system levels.

A profession such as nursing... has the opportunity to positively impact GHIs, perhaps like no

other. Nurses are positioned in settings such as government roles, public health, academia,

clinical care, leadership, and private industries with the ability to develop a creative and effective
network to respond to multifaceted problems. There is a clear need to increase nurse awareness and
education about GHIs, including, but not limited to emerging infectious diseases, human trafficking,
and maternal-newborn health. Professional nurses can contribute as global leaders of change by
becoming active in communities; professional nursing organizations; policy making and advocacy
organizations; and their workplaces. A profession such as nursing, with millions of providers both in
the United States and worldwide, has the opportunity to positively impact GHIs, perhaps like no other.

Authors