Stressors at work and elsewhere: a global survival approach

The United Nations ́ “Agenda 2030” aims, in an integrated manner, to address the entire multitude of major global risks: e.g., to end poverty and hunger, realise the human rights of all, and ensure the lasting protection of the planet and its natural resources. However, recent political changes put this bold initiative at risk. To increase the likelihood of success, higher education institutions worldwide should teach and train today ́s students: tomorrow ́s decision makers, to think both critically and ethically, to learn to cope with ethical dilemmas, and to apply systems-thinking approaches to serious and complex societal problems. The Covid-19 pandemic provides just one example of a complex and serious challenge necessitating such approaches. Promoting decent work, full employment and economic growth is one of the other major challenges. And neither of them can be successfully dealt with in a piecemeal manner.


The world is not on track
In its Sustainable Development Goals Report 2020, the United Nations Department of Economic and Social Affairs (2020), in collaboration with over 200 experts from more than 40 international agencies, concludes that "one third of the way into our SDG journey, the world is not on track to achieve the global Goals by 2030 (…) Forecasts indicate that the  pandemic will push 71 million people back into extreme poverty in 2020 (…) Many of these people are workers in the informal economy, whose incomes dropped by 60 per cent in the first month of the crisis. Half of the workforce -1.6 billion people -support themselves and their families through insecure and often unsafe jobs in the informal economy, and have been significantly affected. The impacts of COVID-19 are also increasing the vulnerability of the world´s one billion slum dwellers (...) As of April 2020, recommended or required workplace closures around the world affected 81 per cent of employers and 66 percent of own account workers (…)" This has already "led to a sharp increase in unemployment and underemployment, a decline in labour income and job-quality challenges." The Report further points to the "much greater risk of child labour, child marriage and child trafficking", that "the world is now facing its worst recession in generations" and that "there is no doubt that the COVID-19 pandemic has shaken the 2030 Agenda for Sustainable Development to its very core." We can, indeed must, cope with the situation and trends described above: by promoting "sustainable development" (SD). SD is usually defined as "a development that satisfies today´s needs: -without jeopardising the ability of future generations to satisfy their needs" (my italics) according to the Brundtland Commission (WCED, 1987).
The question of what actually constitutes SD is an entrance both to an improvement of living and working conditions, to poverty reduction through economic growth: and to protection of the environment.
In the question of method choice, however, opinions differ greatly. Some believe that it requires a return to a simpler life, where people approach nature, live self-sufficiently and locally, and where economic growth stops.
Others argue that SD requires stronger economic growth, where an explosion of technological innovations solves environmental as well as economic and social problems.
I have devoted almost my entire professional life to psychosocial environmental medicine, with a focus on occupational medicine. My intention has been to find ways to prevent noxious stress and disease resulting from it, and to promote health and wellbeing (Levi, 1959(Levi, , 1971(Levi, , 1972Levi & Andersson, 1974;Levi, 1979Levi, , 1981Levi, , 1984Cohen, Levi et al., 1986;Kompier & Levi, 1994;Levi, 2000), in line with what is now referred to as many of the 17 Sustainable Development Goals.
One source of inspiration has been our world´s leading social epidemiologist, Michael Marmot. In his search for the causes for disease as well as for health, his plea was to "look for (and subsequently target) the causes behind the causes"; i.e., the root causes. Marmot´s classical study (2004) of the significance of socioeconomic status, social protection and occupational health provides convincing arguments for such an approach.
A series of recent and most impressive searches for such causes is provided by the World Economic Forum´s annual reports on "Global Risks". They demonstrate that many risks at work and elsewhere are indeed real, powerful and likely to materialise. In addition, they usually are very complex, and highly interconnected, cf. Contrary to what is true for much of today´s political practice, they cannot be ticked off one by one, or dealt with effectively with any quick fixes.
I have also been inspired by the discoverer of the biological stress concept, the late Hans Selye. Discussing the foundation for a good life, Selye disagreed with the Bible´s command "Love thy neighbour as thyself". In its place, he proposed "Earn thy neighbour´s love". To work for a more humane future for humankind and its planet may be such a way (Karasek & Theorell, 1990).
To counteract the global risks described by the World Economic Forum, as well as the present mounting disaffection and disruption across the world, partly due to short-term and silo thinking by many elites, all 193 member states of the United Nations have agreed on an Agenda 2030, comprising 17 very ambitious Sustainable Development Goals (SDGs), and 169 targets. The President of the International Association of Universities (IAU), Professor Pam Fredman, has inspired me to try to integrate the latter approach with what Bo Rothstein and I initiated, promoting critical-ethical and systems thinking in all higher education (Poznan Declaration, 2014).

Focusing on the causes behind the causes: Agenda 2030
The SDGs are concerned with a wide variety of stressors, and accordingly intend to reach an entire package of interacting goals: end poverty; end hunger; encourage good health and well-being; provide quality education; promote gender equality; provide clean water and sanitation; promote affordable and clean energy; provide decent work and economic growth; address industry, innovation and infrastructure; reduce inequalities; develop sustainable cities and communities; encourage responsible consumption and production; take action on climate change; promote life below water; promote life on land; work towards peace, justice and strong institutions; and create partnerships to achieve these goals.
However, recent political changes put these ambitions at risk. To increase the likelihood of success for these 17 SDGs, higher education institutions worldwide must teach and train today's students: tomorrow's decision-makers, to think both critically and ethically, to learn to cope with ethical dilemmas and apply systems-thinking approaches to serious and complex societal problems Hedenus et al., 2018). This concerns professionals belonging to the health, economy, technology, law and many other sectors.
Needless to say, the resulting stress and pathogenic effects of noxious exposures also depend on our individual and collective resilience and coping ability. Such aspects remain important targets for disease prevention and health promotion.

Adjusting the "foot" and/or the "shoe"
But they can never replace the situational factors focused on in this paper. True, causality may imply a range of relationships. It can mean that a certain exposure or characteristic is necessary: enough for a certain disease to develop (such as exposure to lead causing lead poisoning). An exposure may also be sufficient: no additional influences or vulnerabilities are necessary. Or exposure may be contributory, and neither necessary nor sufficient. The question also remains about whether an exposure really causes a specific disease: or if it "just" aggravates it, accelerates its course, or triggers its symptoms. If we keep all these options in mind, it becomes clear that work-related exposures may very often be a prerequisite for the development of specific diseases, as a sine qua non. On the other hand, it becomes equally clear that they may contribute to a wide variety of morbidity and mortality, a much wider spectrum than is usually realised.
As pointed out in the European Commission´s Guidance on Work-Related Stress (Levi, 2000), work-related disease prevention programmes can aim at a variety of targets, and be based on various philosophies. If the conditions at work: the "shoe", do not fit the worker: the "foot", one approach may be to urge the "shoe factories" to manufacture a wider variety of shoes in different sizes and configurations to fit every, or almost every, conceivable foot. Whenever possible, such instructions to the "shoe factories" should be evidence-based: in other words, based on measurements of a random sample of all feet, all shoes, and of the existing fit. This is a first, diagnostic, step in a primary prevention approach on a population level.
Another approach, again based on primary prevention, aims at finding the right "shoe" for each individual "foot": promoting "the right person in the right place." A third, complementary approach is to provide the owner of each foot with a "lasting device" to adjust available shoes to fit his or her feet.
A fourth, very important approach can address the inequity of various feet in various shoes (Marmot, 2004(Marmot, , 2015.
Examples of such amendments would be avoiding, e.g., overemployment, unemployment, exposure to noxious physical, chemical, and biological agents, organisational inadequacies, bullying, and insufficient training and instruction.

Developing critical and ethical leaders of the future
Students need to be made aware of the local, regional and global contexts in which they live and make decisions. Many of today's students do not grasp their role in, and responsibility to, the world, and large numbers do not seem to care.
A single course at college can only ever be a beginning. Families, media, religious bodies, primary and secondary schools and workplaces as well as higher education institutions must be educated and recruited to play their part.
The 2030 Agenda for Sustainable Development aims to promote the entire cluster of 17 SDGs and 169 targets. The critical-ethical analytical skills and systems-based approach mentioned above are indispensable prerequisites to achieving this.
By 'critical' we may refer to the application of careful, exact evaluation and judgement. By 'ethical' we may refer to a set of principles about the right way to behave. By 'systems' we may refer to a group of interacting, interrelated or interdependent elements forming a complex whole.
All this could and should be organised and implemented in collaboration with the social partners.
Universities need to start to become ethical leaders by looking first at themselves and lead by example. The Council for Higher Education Accreditation/International Quality Group and UNESCO's International Institute for Educational Planning have issued an advisory statement on combating 'corruption' in higher education internationally (CHEA/CIQG IIEP-UNESCO, 2016).
The statement, however, uses 'corruption' as a general term to designate a broad variety of malpractice in institutions of higher education, such as appropriation, bribery, cheating, corruption, deceit, embezzlement, extortion, favouritism, fraud, graft, harassment, nepotism, etc.: an ABC of misconduct.
To deliver the badly needed SDGs and targets, we need trustworthy, ethical, honest and impartial government institutions that exercise public power, oversee policies fairly and take into account their range, complexity and occasional incompatibility. These institutions are much more likely to promote trust and social capital which in turn improves health and wellbeing. Tackling corruption is vital .
It may also be noted that as early as in the mid-to-late 1800s, major companies have tried to give back to society while bolstering brand reputation. American economist Howard Bowen (1953) introduced the term "Corporate Social Responsibility, and the US Committee for Economic Development (1971) coined the concept of the "Social Contract" between businesses and society.

Over 2.000 universities and colleges world-wide
The International Association of Universities (IAU) with its over 640 member universities world-wide, has engaged itself for Agenda 2030 and its implementation, in collaboration with the Association of Commonwealth Universities and the Agence Universitaire de Francophonie. These three global university networks, with their over 2.000 institutions, have called on the higher education sector to adopt policies which maximize their contribution to the Agenda 2030 across teaching, research and community engagement, and to incorporate education about and for sustainable development into undergraduate curricula. And IAU has designated 16 universities, each taking on one of the first 16 SDGs, and each in collaboration with a dozen or so allies for its specific purpose, but with an awareness of the dynamic interaction between all ingredients of the system. Work on goal 17, which will consist of multiple organizations working together, is led by IAU. Gradually, additional institutions will be invited on board. The Cluster will be supported, monitored and steered by an IAU Working Group.

The European Network Occupational Safety and Health
SDG 8 aims at "promoting sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all". This contrasts sharply with our current world´s labour market reality. Un-and underemployment remains high (ILO, 2019; UN, 2020) "Working conditions are often precarious and pathogenic, and in some countries child labour and slavery are not yet under control. As summarized by ILO, "unemployment and decent work deficits remain high" (ILO, 2019).
The resulting cluster of challenges to higher education inspired a major Conference on "Rethinking Higher Education, inspired by the Sustainable Development Goals", organised by Karolinska institute in collaboration with University of Gothenburg, Chalmers University of Technology and Royal Swedish Academy of Sciences (Karolinska institutet, 2019).
One of the Conference´s Workshops, "Decent work and economic development", subsequently developed into a Task Group: "SDG 8 -Promoting decent work and productive employment through Higher Education", recently endorsed by the ILO-led "Global Occupational Safety and Health Coalition". This task group comprises a dozen international experts and is managed by Johannes Siegrist (University of Duesseldorf) and the ENETOSH Group "Mainstreaming OSH into Education", coordinated by Dr. Ulrike Bollmann (Dresden).
The Task Group aims to collect and analyse examples of the implementation of SDG 8 in higher education, establishing links to SDG 3 and focusing on the quality of education SDG 4.

Involvement of the World Health Organisation (WHO)
The adoption of the 2030 Agenda for Sustainable Development and the Sustainable Development Goals have provided a framework within which to strengthen actions to improve health and well-being for all and ensure no one is left behind. Despite overall improvements in health and well-being in the WHO European Region, inequities within countries persist (WHO, 2019).
The WHO report identifies five essential conditions needed to create and sustain a healthy life for all: good quality and accessible health services; income security and social protection; decent living conditions; social and human capital and decent work and employment conditions. Policy actions are needed to address all five conditions. WHO´s Health Equity Status Report also considers the drivers of health equity, namely the factors fundamental to creating more equitable societies: policy coherence, accountability, social participation and empowerment.
Based on the above, WHO´s Regional Committee for Europe (2019) in its resolution on "Healthy, Prosperous Lives for All", requested its Regional Director: • To support Member States in placing health equity at the centre of sustainable development and inclusive economies.
• To take the lead in exploring ways of bringing together policymakers from other sectors responsible for the determinants of health, including education, housing, employment, the environment, and poverty reduction, in order to develop a systematic approach to taking action.

Words do not cook rice: next steps
According to the Agenda 2030´s Target 4.7, it should be ensured that "by 2030 all learners (should have acquired) knowledge and skills needed to promote sustainable development". And the European Commission´s Strategy on CSR aims at "integration of CSR into education, training and research." It is obvious that such targets fit exceedingly well into the aim of this European Journal for Workplace Innovation.
But as a Chinese proverb formulates it: "words do not cook rice." There exists a very considerable gap between what we know, and what we implement (Levi, 2017).
Recognising the university sector's potential and responsibility to help shape the moral contours of society for the better and given the societal benefits from increased social capital, universities and institutions of higher education should shoulder their role as key agents of change, as stated in the Compostela Group of Universities' Poznan Declaration (2014). They should, inter Alia: • Endorse a cross-faculty approach to broaden the curricula to include components of critical-ethical analysis and systems thinking (and, of course, Agenda 2030 based thinking, my addition).
• Appreciate the unique opportunity they have to shape professional identities. At universities, the norms and boundaries of acceptable behaviour are to a large extent set for a number of professions. Universities have a possibility as well as a responsibility to help shape the normative contours of society for the better.
• Teach the teachers through the provision of pedagogical resources and training to a wide range of faculty.
• Develop partnerships with other universities, networks, national authorities for higher education and civil society organisations championing the critical-ethical agenda.
• Co-ordinate with national education authorities and social partners with regard to fulfilling the state's obligation under the UN Agenda 2030 SDGs.
• Talk the talk and walk the walk. In addition to teaching critical-ethical behaviour and promoting systems thinking, it is crucial that higher education institutions: as agents providing public goods, act accordingly, ensuring impartiality in teaching, student assessment and research and that matters regarding awards of degrees, employment and promotions are based on legitimate, transparent and objective criteria.
The Poznan Declaration was issued in 2014, i.e., one year before Agenda 2030. As mentioned above, an important addition to the declaration would be the Agenda´s Target 4.7: "By 2030, ensure that all learners acquire the knowledge and skills needed to promote sustainable development, including, among others, through education for sustainable development and sustainable lifestyles, human rights, gender equality, promotion of a culture of peace and non-violence, global citizenship."

Low costs, high gain
Considering the relatively low costs of implementation and the possible very considerable societal gains if these proposals are implemented broadly, this initiative has the potential to be extremely cost efficient in the long term. More important, however, is that, ethically, it is the right thing to do. This is why we propose additional high-level conferences on such issues, with a focus on the implementation of Agenda 2030 (what should be taught, and how). Based on the outcomes of these, recommendations should be made regarding the necessary redesign of all higher education: -and for its subsequent and urgent implementation.