At a time when actual or potential global events are having, or are likely to have, significant impact on societies, it is timely to revisit ‘global citizenship’ and explore the relevance of the concept to health and social care. This paper explores its relevance to modern day health and social care professionals, why there needs to be a greater understanding of it and whether it can be incorporated into pre-qualifying education.
The relevance of global citizenship in society as a whole, and to health and social care specifically, has never been more important. The potential risks of ignoring global citizenship and the knowledge and skills needed to provide care in a global context are numerous. The inclusion of the concept in health and social care education is limited. This paper explores some of the ideas that global citizenship incorporates, why health and social care professionals need a greater understanding of it and what knowledge and skills need to be incorporated into pre-qualifying education, together with how best that might be achieved.
Defining global citizenship
There is no single definition of global citizenship, but it has been described as a concept representing social consciousness and responsibility, and a public good towards the wider world, rather than accountability within national borders (Israel, 2012; Unesco 2014; Oxfam, 2015a; 2015b). This paper broadly adopts the definition put forward by Oxfam (2015a) (Box 1).
It is important to distinguish between global citizenship and globalisation. The term globalisation refers to the emergence of international networks, more often belonging to economic and social systems. The Oxford English Dictionary (2018) defines globalisation as:
‘… the process by which businesses or other organizations develop international influence or start operating on an international scale, widely considered to be at the expense of national identity.’
However, a more relevant and workable definition is that formulated by Giddons (1990:64) which, although it is 30 years old, still holds true today. He defines globalisation as the:
‘intensification of worldwide social relations which link distant localities in such a way that local happenings are shaped by events occurring many miles away and vice versa.’
The dawn of global citizenship
The concept of global citizenship is not new and it has had several manifestations over time. Diogenes and Socrates are thought to have shaped its development, believing they were able to function as ‘doctor to men's souls’ and improve their morality (Schattle, 2008). Kant's ethical universalism concept, in which any action has implications on anyone else regardless of circumstance, can be seen to be a basis of the beliefs behind global citizenship to the present day (Rolf, 2018).
The concept of global citizenship emerged from the inability of the League of Nations to prevent the Second World War and the foundation of the United Nations (UN, 2017), which was fashioned explicitly, to guard against a repetition of the atrocities that had occurred in war (UN, 2017). Today, the UN and its specialised agencies—the World Health Organization (WHO), Unesco and Unicef—continue working to lead and promote: global peace, human rights, international co-operation, better global health, a reduction in equalities and progress towards global sustainable development.
Global citizenship for health
The Ottowa Charter for Health Promotion (WHO, 1986) was the first international agreement that began to address public health and to recognise the requirements needed for health, namely peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equality.
The Global Citizens' Initiative (2017:6) proposes that the shared elements of a global community include:
‘Human rights, religious pluralism, gender equity, the rule of law, participatory governance, internet freedom, environmental protection, sustainable economic growth, poverty alleviation, prevention and cessation of conflicts between countries, elimination of weapons of mass destruction, humanitarian assistance, and the celebration of cultural diversity.’
These clearly reflect the shared values and goals of public health as acknowledged by Guise (2015). Fairness and equity are fundamental to public health practice and the principles of global citizenship. However, the question of a peaceful world appears to be repeatedly ignored in public health, as has any consideration about environmental sustainability. Television programmes, such as David Attenborough's Blue Planet and Liz Bonnin's Drowning in Plastic, both originally shown on the BBC in recent years, have pushed the issue of environmental sustainability up the public agenda, both in the UK and globally.
Other developments in relation to this have been the rapid growth in popularity of the environmental pressure group Extinction Rebellion and the global phenomena of young activists such as Greta Thunberg.
Prior to this, Dahlgren and Whitehead (1991) had argued that the omission of peace and environmental sustainability was due to an emphasis of the wider socioeconomic determinants of health, such as housing, sanitation, education, and living and working conditions. The public health model was fashioned to exemplify connections between, and the consequences of, economic deficiency and health inequalities. However, although Dahlgren and Whitehead's (1991) public health model is the one most commonly used to represent the determinants of health, its scope has not been broadened to include things such as peace and sustainability, which means that these issues are excluded from the broader spectrum of the health determinants.
Globalisation of health and social care professionals
In the UK, most health and social care professionals receive their education at university, and at the same time undertake some form of practice placements in organisations with which the universities have partnerships or collaborative arrangements.
Universities are actively attempting to widen participation to ‘address differences in access and progress in higher education between students from different social groups’ (Connell-Smith and Hubble, 2018). The issue of reducing social exclusion is something that the Office for Students (2018) has begun to focus on. The demographics of student populations have begun to change. Weale and Barr (2018) claimed that widening participation by UK universities had slowed down, although their conclusions were based on 2016/17 data. The Times and Sunday Times Good University Guide has acknowledged the importance of social inclusion by launching a University of the Year for Social Inclusion award.
However, it is not only university student populations that are multinational and multicultural, so too are the communities within which the universities' partner organisations are situated. Consequently, people in these areas who are in need of health and social care are also multinational and multicultural. Universities, therefore, need to ensure that their curricula reflect this multinational and multiethnic demographic. Student and staff exchanges, and student visits to undertake associated activities and meet people in other countries, clearly have a positive impact on students' understanding of the culture/society they visit. Such activities also enhance students' employability by broadening their experiences.
What is also needed, however, is the integration of the global experience into the theoretical underpinnings of their learning. This has often been a challenge and remains so in many areas. For example, there has been a large Afro-Caribbean population in the UK for many years. A significant number of this population has sickle cell anaemia and thalassaemia, yet relatively little is included about this in health and social care curricula, which not only fails to cover the condition, but also how individuals should be cared for or treated. Additionally, there is no term for depression in the cultures of many Asian communities, who often present with or talk about the physical manifestation of their illness (Illingworth, 2019). Again, this is rarely incorporated in the curricula.
However, universities are ideally placed to address the neglected areas of peace and environmental sustainability. Although there has been recent conversation about freedom of expression within universities, they remain an excellent environment for fostering debate.
Any health or social care professional should, indeed must, be cognizant of the impact of when peace breaks down. This can often lead to civil unrest or even war, and with these come inevitable casualties (physical and mental). People become displaced and the result is a movement of refugees across continents, as we are witnessing today. The impact of displacement affects both the mental and physical health of refugees, and their wellbeing will in turn affect the communities that they become part of, which, in turn impacts on the local health and social care systems.
Although societal awareness about environmental sustainability has increased, it remains an issue that is not usually addressed in health and social care professionals' education. Tilman and Clark (2014:518) suggested that the growth in incomes and urbanisation has fashioned a ‘… global dietary transition …’, whereby traditional diets are being changed for diets high in ‘… refined sugars, fats, oils and meats’. They also argue that this will, in the longer term, have a major impact on people's health, increasing the prevalence of, for example, coronary heart disease and type 2 diabetes. Clearly these and other health issues are already major concerns for healthcare providers. The focus of the NHS Long Term Plan (NHS England, NHS Improvement, 2019) on preventive strategies, linked to nutrition degree programmes, may perhaps be key in helping to address these issues.
Conclusion
For universities, global citizenship has to be central to their functioning from an academic and research perspective—it is not just about giving students and staff opportunities to travel abroad. Nevertheless, travelling abroad, whether part of studies/work or for holidays can open people's minds to alternative cultures. Society has and continues to reconfigure (UN General Assembly, 2017).
An understanding of the complexities of globalisation, the growth of multinational and muticultural societies, plus the transcendence of national boundaries and the challenges this brings, needs to become integral to the education of health and social care professionals—to ensure that they can address the increasing complexity of society's need(s).
Globalisation allows barriers to be broken down and for universities to make connections anywhere in the world and, through research and collaboration, contribute to knowledge exchange and growth.
Universities are delivering education in turbulent times. In the UK, there is concern about the apparent fall in applications and the financial challenges universities will face as a consequence, as well as the ensuing shortage of educated professionals in health and social care. The UK government and opposition parties are also questioning the current funding arrangements for higher education, but even with the publication of the Augar review (Department for Education, 2019) there is, as yet, no clear steer as to the likely recommendations.
The uncertainty of what Brexit will bring and how the changes are likely to affect universities are further challenges facing the higher education sector. However, if universities' health and social care faculties were to fully embrace the public health model, with the inclusion of peace and environmental sustainability, they would be in a much better position to survive and, indeed, grow by challenging and working to achieve global citizenship within their programmes.