Human Rights and Nursing at WHO
From Nursing Ethics, 1880s to the Present (p. 365-371)
Used by permission 2024 © Marsha Fowler
Chapter 11 Notes
Ethics and human rights—my personal beliefs and commitment have their very early roots in my mother’s anguish over the death of her first child, a three‑year‑old, a week after Hitler marched into Vienna. Who cared for a hospitalized Jewish child then? In March 1938, fascism and racism destroyed her world, threatening not only the livelihood, but life itself of her family and community. Her personal anguish of loss fused with realizing the frailty of a democracy and the failings of human decency. She had not understood it was coming: “We did not care for politics, so politics cared for us.” My father was incarcerated for being a Jew, but they were lucky, unlike millions of others. They managed to leave and become refugees.
An early lesson and an early demand: remaining silent in the face of injustice is evil. Social inequality and racism are evil—at age 80 today, my mother is still present as a daily yardstick. My parents returned to Vienna after World War II. Anti-Semitism and racism and the memory of the Holocaust were all present, while my brother and I were privileged children—loved by “well‑to‑do” parents, who had been able to build a new livelihood in New Zealand.
A left wing‑Zionist youth movement added the “ideological layer” to the emotional; learning through simulated trials on ethical dilemmas related to opposing the Apartheid regime or the use of the atom bomb—discussions of adolescents developing a “Weltanschauung.”
I chose nursing school, not out of a calling, but the understanding that it did not demand the discipline of university study, which I lacked at the time. And it promised a profession after only three years, enabling me to leave Vienna and emigrate to Israel. In June 1967, I lived the Israeli victory of the Six‑Day War in the ICU of a large public hospital—18- and 19-year-old soldiers, dying or crippled for life, brought by helicopters from the Golan Heights. No joy over Jerusalem reunited could blind me to the insanity of war.
Realizing how little I knew, I took advantage of an opportunity that arose to study oncology nursing at New York University (NYU) and Memorial Sloan Kettering (formerly James Ewing Hospital) in New York. It was the first time I understood that nursing was a serious intellectual and emotional challenge. Dr. Norma Owens, the inspiring black nurse who headed the program, Inga Thornblad, a won- derful clinician and teacher, and Hiroko Minami, a student colleague, became my mentors—yes, I had been lucky to blindly choose our profession. It would enable me lifelong learning, helping me to find meaning and “my way.”
Tel-Aviv University had opened a post-basic nursing program, and I was accepted. An early assignment was a paper on “What do I believe?” related to nursing, an assignment to clarify basic values—equity, respect for person, and discussing dilemmas. I was working as a staff nurse, then a clinical instructor, so real-life ex- amples were plentiful. Reva Rubin and Jeanne Quint‑Benoliel, visiting professors, opened special windows.
In 1972, Professor Anne Davis came to Israel to present in an international conference; we met. I had been accepted to the University of California, San Francisco (UCSF) for a master’s program. Anne subsequently became my lifelong mentor and later friend.
I returned to Israel to fulfill my teaching obligation, then returned to UCSF to study toward a Doctor of Nursing Science (today a PhD) degree. Professors Anne Davis and Pat Underwood (nursing), Anselm Strauss (sociology), Margaret Clark (medical anthropology), and Maida Turner (aging and human development), as well as American and international student colleagues, were deeply influential to me.
Returning to Israel, my work life was divided between teaching at Tel-Aviv University and later creating a nursing baccalaureate program by uniting six diploma schools (a human relations challenge!) and working with the Kupat Holim Clalit Health Fund, at the time the major health-care provider in the country, to develop long-term care services for the whole country. Dr. Lea Zwanger—a nurse who had fought in the Palmach (the underground movement to gain Israel’s independence), politically committed, opinionated, demanding, and with humor—was a different role model and boss.
We planned educational and research projects with the primary health-care nurses in Kupat Holim’s clinics. They “suddenly” became aware of demented older persons living in their catchment areas and that families were caring for them. It had not been on their radar. My dissertation had been on family caregiving of demented elderly persons. Together with Baruch Ovadia, responsible for social work in Kupat Holim, we held courses for the “long‑term care teams,” which had been created after the 1973 Yom Kippur War. Thousands of dependent patients were then “referred to the community” to free hospital beds for wounded soldiers. The teams’ role was advice and guidance of the primary care teams throughout the country.
We taught and practiced teamwork, case management, and counseling and also needed medical involvement. So, Dr. Hava Sroka, a neurologist, joined us. She mentored students while they worked with her to support the family caregivers of her patients. We knew that our fund was essentially a medical insurance scheme. We believed that our aging members deserved our care, even for long-term problems not legally covered under medical insurance, and were ready to bend rules of eligibility. When a national committee to prepare a new law on “long‑term care” was set up, I represented nursing in the university and the sick fund on the committee. Questions of “What does justice require?” as the rights of patients, caregivers, and intergenerational families’ responsibility, versus population solidarity, occupied our discussions.
At one of the international nursing conferences, I heard Professor Astrid Norberg on feeding of demented patients. At the evening reception, I explained to Astrid that Swedish solutions would be unacceptable in Israel. “Why not? We should ex- plore!” she responded, which was the beginning of an international seven-country research project on (force) feeding end-stage dementia and terminally ill cancer patients. Astrid is the lead nurse researcher in the field; Anne Davis led the American group.
Meanwhile, I became a consultant to a World Health Organization (WHO) group in Manila on “Health care of the elderly,” learning from the experienced Dutch consultant Dr. Zonnenfeld. A consultancy on the “Assessment and plan- ning of health care services for the elderly” in Fiji followed in 1983. My longtime friend Dr. Tamar Berman, a sociologist, advised me: “You ask everyone, individuals and then in groups. You always return to them to share your findings and ask them if they agreed, ask them what you have not understood, or what you have misunderstood; over and over again.” My final report to the Fiji minister of health recommended: “Establish a long‑term care fund, based in law, while your demo- graphics still make it economically feasible.” A New Zealand economist Denis Rose helped me determine a way of easily financing such a proposal. The minister decided, “Alas, it is not a priority.” Fiji, as with so many developed countries (mine included), decided to wait for such legislation until it was much too late for many persons, patients, and family members alike, who would have needed the support. Another WHO consultancy ended in bitter disappointment. For more than three years, I worked with Austrian nurses in Graz, Styria, on a demonstration research project on how to care for patients in the community, old persons who had been in long-term care facilities for years and even decades. All was ready for implementation when we received notification to stop the project; the hospital lobby feared losing large insurance funds.
In 1989, the Israeli Ministry of Foreign Affairs submitted my CV as a candidate for the WHO Chief Scientist Nursing position. I did not consider it a realistic pos- sibility. Years before, Hiroko Minami (now a highly regarded nursing professor in Japan) and I had approached WHO in Geneva, to inquire about job offerings in the nursing division. We were dismissed out of hand. I was selected for the post, but I had finally settled in Tel‑Aviv and felt at home. I loved my work and thought it was important. Should I again uproot? The offer was hard to reject. I accepted and a steep, lonely learning curve began. While being aware of bureaucratic requirements and the challenge of interdisciplinary and international work, nothing had prepared me for WHO. In the first month, in a large meeting, I was told that I was remiss in not mentioning “primary health care and health for all”; when asked to give a keynote on the health of children, I told my boss that I was not knowledgeable on children’s health. His response: “In this job you are expected to know it all.” Well, I learnt, not all, but how to get around knowing less. Asha Singh Williams, an Indian colleague and friend, took me under her wing with Swiss nursing colleagues giving support—Dr. Rosette Poletti and Dr. Annemarie Kesselring, who took me for hikes on weekends.
The nursing position in WHO is a difficult one. You have only a secretary and in order to make a difference you must work through all the other divisions, mainly physicians, who do not consider nursing important. The International Council of Nurses (ICN) was an important partner. I found it crucial to build links with the regions. The regional nurse advisors became a wonderful team: Dr. Sandra Land and Maricel Manfredi in the PAHO/AMRO office in Washington, Jane Salvage in the EURO office in Copenhagen, Dr. Enaam Abu Youssef in the EMRO office in Alexandria (not thrilled to work with an Israeli, but wonderful once I was in post), Dr. Sally Bisch and then Dr. Duangvadee Sungkhobol in the SEARO office in New Delhi, and, not least, Kathy Fritsch in the WPRO office in Manila.
Among many projects of my eight years in the nursing position was a letter to the world chief nurses to do all in their power to stop female genital mutilation (FGM) and forbid nurses and midwives from participating. A bureaucratic feat was creating a two-person committee (myself and my assistant director general) where all the new WHO job vacancy notices would come to me. I could then discuss it with the respective division director, asking to change the requirement from “medical doctor” (a major barrier for nurses in applying to posts) to “technical officer,” thus opening positions for nurses. I worked 12-hour days and worried about what I was accomplishing. I remembered the words of my Israeli colleague: “If you would come to work on my ward, I would know within a week if you are any good; if you would come to work in my hospital, it would take me a year; in that position—who can ever tell?”
In January 1998, Director General Dr. Hiroshi Nakajima appointed me Director, Division of Human Resources Development/Capacity Building. Dean Margretta Styles had declared at the ICN Quadrennial Conference in Los Angeles that, “Once a nurse will fill that WHO position, nursing will have made it.” Well, it had not made the difference for nursing. On a personal level it did make a difference, as my opinions suddenly carried weight—the same opinions, but now expressed by “the director” and not by “the nurse.”
In early 1999, the new Director General, Dr. Brundtland, asked all of WHO HQ directors to resign from their positions and tell her what they wanted to work on. I chose “home‑based and long‑term care.”
Thus, my most productive three years at WHO began. With the help of experts from around the world, we managed to publish more than ten reports/books, from case studies in poor countries on caregiving to HIV/AIDS patients, to textbooks on long-term care (LTC) in industrialized and developing countries. Betty Havens from Canada and the Jerusalem Brookdale Institute were my prime LTC expert advisors.
The two publications closest to my heart were global forecasts of need for LTC in all 192 member states. The “dependency needs” statistics were based on the Global Burden of Disease data, which included LTC needs throughout the life cy- cle. The information on the WHO website gave countries that might have the politi- cal will for action the needed information, with the trends reliable, if not the actual data. One of my greatest disappointments and sadnesses was that the information was deleted from the WHO website after I retired from WHO.
The other publication, still available on the WHO website, is “Ethical choices in long-term care: what does justice require?” Working with philosopher Daniel Wikler on “ethics” in WHO and a group of nurses, physicians, philosophers, an- thropologists, and sociologists from around the globe, we made an effort to answer questions of how to re‑think and address the challenge of future long‑term care; what is (a) fair to the persons requiring care? (b) fair to the family caregivers? (3) fair to the care workers? and (d) fair to “care‑work” exporting and “care‑work” importing countries?
Over these years, I had the privilege of choosing and working with colleagues and teams from around the world, who knew far more on each and every specific topic, than I did. Collaboration pays off.
With my 60th birthday in December of 2002, I had to retire. Dr. Ruth Levin, a longtime friend, convinced me to join her on faculty at Yezreel Valley College in Israel’s periphery. My task would be to establish a new baccalaureate nursing program.
We soon realized that our main challenge was to ensure “cultural safety” (a concept developed by Maori nurses, taking power differences in cultural relationships into account) for our students and faculty. About half our students were Palestinian (Arab) Israelis, with the other half a mix of different Jewish Israeli identities (kibbutz members, immigrants from the former Soviet Union, etc.). Classes and seminars in ethics and communication courses, jointly led by nurse clinicians and psychologists, became the backbone of the program. The ongoing qualitative evaluation, led by Dr. Daniella Arieli, an anthropologist, showed us that we faced a serious challenge with relationships between Jews and Arabs, within the larger reality of ongoing violent conflict and war. Working on these issues became our major focus, led by Professor Victor Friedman, an organizational psychologist.
In hospitals, I saw Ethiopian Jewish immigrant women solely in roles of clean- ing (my mother’s job in England and New Zealand as a refugee) and as nurse aides. I realized that their educational background had not prepared them for a university/ college entrance exam. So, we started a preparatory program, got full scholarships, and planned extensive academic and social support. Within years, we had a large group of Ethiopian Jewish immigrant students with their own leadership group, who passed the national licensure exam. This “Opportunity for Success” program has by now more than 60 graduate nurses. It is an initiative I am proud of.
All through the last 45 years, my brother, Dr. Yair Hirschfeld, a historian, worked in backbench diplomacy, seeking a just solution with our Palestinian neighbors. The Oslo Accords was a personal accomplishment. His work has informed me over the years on the broader political issues related to our conflict.
WHO had asked me to edit a special issue of the Israeli–Palestinian journal Bridges on nursing. This began a more than 20-year collaboration and friendship with Dr. Amal Abu Awad, at the time a young Palestinian nurse educator. We began mutual exchange visits of groups of nurses. Upon their request, I found volun- teer nurses from a Scottish WHO Nursing Collaborating Center to teach a large group of Palestinian nurses, hoping to enter PhD studies, statistics, and research methodology.
At ICN’s 25th Quadrennial Congress in Melbourne, I was able to represent the Israeli Nurses Association and welcome, in our name, the Palestinian Nurses As- sociation to ICN. It remains the only international organization that Palestinians could join without a struggle.
Dr. Nurith Wagner, a longtime friend and our leading Israeli nurse ethics ex- pert, convinced me to join Nurses of the Middle East (NME). Following meetings and yearly conferences, enabling mainly Palestinian and Israeli nurses to meet, Dr. Dominique Egger, a former WHO Swiss colleague and partner, facilitated a ser‑ ies of workshops where together Palestinian and Israeli nurses identified common problems, seeking ways to address them. Two of the major issues identified were nurse referrals (some 40,000 Palestinian patients were hospitalized yearly in Is- rael) and infection control. Nurith and I remain active with “Physicians for Human Rights, Israel,” their ethics committee, their fights for social justice, and access to health care for Palestinians, asylum seekers and migrants, and for human rights and quality health care for prisoners.
Most recently, the NGO Rozana together with the NME received a large USAID grant to work with nurses from six Palestinian and six Israeli hospitals to ad- vance quality of care. In October 2022, Nurith Wagner and I, as a team, received a wonderful gift, the Thai Nursing Royal Srinagarindra Award; we received it for our career-long work in ethics and human rights. Alas, with the recent political developments of populism, growing fascism and racism, continued work on human rights for all is a growing challenge facing nursing—and facing all of us.