1. Primeau, Marlena Seibert DNP, FNP-BC, BSHECS

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Healthcare is organic. This fundamental aspect of healthcare was slowly recognized and acknowledged over my years of teaching a Global Health course and traveling abroad with students. After interacting with nurses, medical personnel, and the general public in various countries, it became evident that a nation's healthcare system is not just a static entity. Healthcare is created, then grows, develops, and changes according to the needs of a nation and the culture, history, and personality of its citizens.


Beginning in the late 1970s, a Public Broadcasting System documentary series entitled Connections (An Alternate View of Change) looked at science and inventions from both an interdisciplinary perspective and as a largely unintentional interaction of discrete events. As creator and science historian James Burke noted, the development of anything in our world cannot be viewed as a singular event, but rather as a network of interrelated events, with each of those events occurring for various individual reasons with no awareness of the possible future results. Burke suggested several corollaries to his theory: first, that the modern world has no idea where today's "isolated" events will lead, second that the probable increase in both speed and complexity of these connections will impact individual freedom and privacy, and third, the probable consequences to the entire system in case of a breakup or collapse of one of the interconnected networks.1 In many ways, healthcare systems mimic Burke's theory on how the world interconnects. Healthcare does not occur in isolation; it is developed and changed by people, events, and the connections between them. History, culture, education, politics, and geography all play an integral part in contemporary healthcare; comparisons of these topics add dimension and depth to the learning experienced and insight developed by the students in my Global Health course.


What does historical perspective bring to understanding healthcare systems, and what role does a nation's history play in current-day healthcare? The history of a nation illuminates that nation's view of individual health and the development of its healthcare system. The aftermath of war, the immediacy of a national trauma, and the realities of public health concerns, such as infectious disease or a widespread disaster, all help determine the role that healthcare plays in the lives of a country's citizens.2 In many parts of Europe, World War II is not just a distant memory; it is a remembrance that is integral to the national consciousness. With the influx of refugees, the damaged cities, and the necessary rebuilding of a society, systemic programs such as universal health coverage were both an imperative and a reasonable solution for the postwar problems experienced by many European countries. William Beveridge, one of the creators of Britain's welfare state, said in 1948 that "social security and world security were indissolubly linked."3(p262)


Professional nursing has been, and continues to be, shaped by historical events, from Florence Nightingale's response to the needs of the Crimean war soldiers to the experiences of the nurses in Louisiana and Mississippi who worked in nursing homes during Hurricane Katrina. In a medical corollary to James Burke's theory, present-day healthcare professionals are often so focused on current concerns that the larger, and longer-term, implications may be ignored or overlooked. It would seem to be significant that education on historical perspectives of health is usually taught only tangentially in nursing and medical schools, where very full curriculums are generally focused on current knowledge and practice standards. It is important, at some point, to take the long view and remember that all events experienced by a nation shape and change the long-term view of healthcare goals and in what manner they should be achieved.


With that in mind, the following question must be considered: Does the educational preparation of healthcare providers influence the direction of the entire country's healthcare system or simply define how an individual practitioner performs? There is more depth to the education of a healthcare provider than clinical preparation. An interesting phenomenon noted during our travels was a comparison of the nursing schools in the countries visited; we discovered that remarkable similarities exist between simulation laboratories in a Dutch nursing school and those in a university in Alabama, yet the professional lives of those nurses will differ radically, based on their county's health beliefs and ideas about healthcare. The daily duties and responsibilities of nurses in the United Kingdom working in community health are drastically different from those of public health nurses in the United States, yet the core training and competencies are comparable across countries. Broadening the scope of a nursing student's understanding of the world changes the gestalt of the learning experience. Facilitating learning experiences outside traditional academia assists nurses in decreasing ethnocentrism, broadening worldviews, and increasing one's understanding of how cultural and political forces impact healthcare and improve outcomes.


How do those cultural forces impact and influence our healthcare? The psyche of a nation often, and in many ways, defines the healthcare system used by that nation. This influence is not always, or even often, a conscious process. Students who enroll in my Global Health course have learned over the years that cultural values are at the root of any question answered with the statement, "Well, because it is right!" The social environment can be defined as the combination of social connections, physical environments, and cultural norms, patterns, beliefs and processes that influence how people function and relate within a community.4 Cultural mores, views on work and leisure, opinions on individualism and privacy, and sometimes simple practicality all play a part in the healthcare choices we make. Societal factors, such as the litigiousness of the society and the homogeneity of the citizens, as well as cultural aspects, including the status of healthcare providers and the values of pop culture, all serve as indicators of societal acceptance of healthcare practices. Culture affects decision making within the healthcare environment as well. This includes the power exchange between the patient and the professionals, with cultural issues such as the desire for shared decision making, the health literacy of the patient, the mindset of the practitioner, and the information technology available all impacting the process. The United States, with its direct-to-consumers medication infomercials and healthcare-related television dramas, often has a much higher expectation of health literacy and proactivity from patients than does a country where the expertise of the healthcare provider is the sole determining voice. The widespread use of information technology and social media also influences healthcare by increasing opportunities for consumers to directly access healthcare-related information and to make their health-related political voices heard.


We are all aware of how politics and policy affect healthcare, but what is the underlying mechanism that determines how healthcare impacts political action, which then in turn shapes healthcare? Politics and healthcare are synergistic. Most people know that healthcare lobbyists work to impact health policy, but fewer are aware of how the confusing mix of agendas, friendships, perspectives, and rivalries create healthcare policies that affect nursing and medical jobs and patient care. Social determinants of health, things in both the social environment and our national worldview, directly impact beliefs about healthcare and what role it should play in our lives.5 When traveling in the Netherlands, it was surprising to the American nursing students that legalized prostitution and the decriminalization of drug use were not codified because all Dutch people were favorable toward these practices. What was learned was that the Dutch, a very practical people, developed what they felt were the best workable solutions to particular problems in their society. In the United States, privacy, independence, and individuality, all strong components of the American psyche, play a continuing and definitive part in shaping US healthcare policy from medical privacy laws to state-by-state decisions on Medicaid. Although citizens may not realize it, their choices and decisions in both healthcare and politics are intrinsically linked, and circumscribed by, the parameters of history, culture, and geography.


Although geography may seem to be an unlikely contributor to healthcare development, the geography of a nation plays an integral role in the evolution of a healthcare system. Health geographers focus on using geography to seek answers and insight on health inequalities and barriers to care,6 but geography can be looked at on both a more macroscopic and microscopic level. Something as simple as the size of a country can have a profound effect on one's worldview. For example, in a recent Global Health trip to the Netherlands, American and Dutch nurses and nursing students met to compare professional lives and healthcare practices. The Dutch nurses were perplexed by the chaos of the US healthcare system and were at a loss to understand why the US healthcare system could not be managed more efficiently and productively. In land mass, the Netherlands is approximately the size of Maryland. It was pointed out in the discussion that coordinating US healthcare policy would be similar to coordinating a single healthcare system for the entirety of Europe. The Dutch nurses also had difficulty understanding the sheer size and scope of the United States. A lively discussion centered around the realization that there is a significant gap in understanding between the 2 nursing groups regarding how population density, demographics, natural resources, industrial development, and even public transportation affect access, funding, quality of care, and patient outcomes. Using a broader brush, the science of health geography looks at the relationship of geographical principles and perspectives to disease, health, and healthcare.6 The World Health Organization, through Millennium Development Goals, Sustainable Development Goals, and a recent focus on the global prevalence of noncommunicable diseases, uses principles of health geography to assist in its mission to provide information, direction, and coordination to the global community.7,8 Health issues such as smoking, violence, heart disease, diabetes, and environmental concerns transcend borders and are a current concern whether one lives in Denver, Aberdeen, Istanbul, or Kinshasa.


So, healthcare is organic. It begins with the nature of the people of a nation; bends and changes with education, history, geography, and politics; and becomes an enduring yet dynamic construct. If healthcare is, in truth, a more fluid and malleable entity than we believed, this realization should change our perspective and certainly provides food for thought on what we, as individuals, can bring to the ever-changing landscape of our healthcare system and to the education of our students.




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