Interview: Learning during crises

A change in dietary habits could make the greatest contribution in Germany to the fight against climate change., specially as healthier nutrition is a key medical concern says Prof. Dr. med. Sebastian Schellong

Changing our behaviors, to stop changing the climate

A change in dietary habits could make the greatest contribution in Germany to the fight against climate change. Encouraging patients to eat healthier is a key medical concern for Prof. Dr. med. Sebastian Schellong, Chairman of the German Society for Internal Medicine (German Acronym: DGIM). In this esanum interview, he talks about the impact of climate change and COVID-19 on internal medicine.

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esanum: Professor Schellong, in a recent press release of the German Climate Change and Health Alliance (German acronym: KLUG e.V.) you are quoted as saying that "investments in climate protection are ultimately investments in better health". In your opinion, what measures should be taken now to be better prepared for climate change-related health challenges?

Schellong: The press release refers to a study that was published in the Lancet Planetary Health in February. The study is based on very detailed modelling for nine different, representative countries. The research attempts to model the health impacts that specific sub-sectors would have if certain health-related aspects were to be given greater attention as part of a strategy to meet climate targets. The Lancet study has thus taken a new approach and raised the question: What do we achieve amidst the climate change conjecture if we integrate health aspects into the achievement of climate goals, and pay primary attention to health? So this is the reverse of the other approach. In this way it comes out that the effort for a healthy lifestyle and the effort to reduce global warming are mutually interlocked.

esanum: Are certain clinical issues in internal medicine particularly affected by climate change?

Schellong: The effects of climate change on chronically ill patients are evident insofar as they tend to reach their decompensation limits during extreme weather conditions. I include here patients with underlying diseases of the heart or lungs, as well as the entire population segment that classifies as frail elderly, i.e. those who have only a very narrow range of variation in their fluid balance. With low body weight in old age, fluid balance decompensates due to extreme heat periods, of which we have more frequent occurrences. The same applies to the large cohort of patients with heart failure who also easily reach their breaking point during extreme weather events. Of course, all the factors that accelerate climate change also have something to do with air quality, and of course these effects are particularly bad for those with chronic lung disease. The point of the Lancet study was to say that if we strengthen our efforts to lead healthy lifestyles, then we are, in a sense, also on the track to actively counteract climate change.

esanum: Do you see a special responsibility on the part of physicians and all other health workers to take measures to mitigate the climate crisis?

Schellong: Without wanting to exaggerate the position of physicians, the study shows how close they are to this issue, specially in practical implementation. If you look a little more closely at the study data, you can see the influence of a wide variety of measures - from the energy sector to agriculture. What is fascinating about the case of Germany is that nutrition patterns and changes in agricultural practices would have the greatest effect - much greater than the "modes of transport" or "energy" sectors, for example. That surprised me. So in Germany we have the greatest influence on combating climate change if we actually pay attention to a healthy diet.

This is a direct medical concern. You don't even have to be particularly convinced about the threat of climate change for realising this. If physicians focus their advice further and more strongly on this aspect of nutrition - which they should do anyway for a variety of reasons - then they are already climate activists. This is a particularly good and practical lesson we can draw from the new study. Aspects such as reducing red meat consumption are things we should recommend anyway and continue to recommend strongly. Depending on the target audience and the mood of the patients we are dealing with, we can embed these recommendations in the general concern about climate change.

esanum: From 17 to 20 April 2021, the 127th Congress of the German Society of Internal Medicine will take place, and due to COVID-19 as a fully digital format for the first time. What else will be different this year?

Schellong: The most important thing is that we won't have any attendance events at all. This is a major break in the more than 100-year history of the congress. 2020 was one of the few years in which we had no congress at all. This has otherwise only happened in times of war. This time, of course, we have prepared ourselves and, accordingly, are holding an all-digital congress for the first time in our history. We rejected the possibility of a hybrid congress because we could not foresee at all whether speakers and chairpersons would be able to be present in person or whether any activities could be carried out in mixed formats on site. I think that was the right decision. The closer the date gets, the less likely it is that members will be able to meet and gather. It was a great adventure to transform the entire congress into a digital format. On the other hand, we have a wealth of experience with our congress and media partners. Nevertheless, it is a big, exciting task for us because we still have over 400 individual events with more than 1,000 participants. Coordinating all this will be very exciting.

esanum: The motto of the DGIM Congress 2021 is "Learning from the crisis". What do you think are the most important medical lessons learned from the COVID-19 crisis?

Schellong: The Corona crisis has many different aspects. What fundamentally affects our craft as internists is that a new disease has come on the scene, which we have to understand as a disease. A lot of new knowledge is needed here, which changes practically every week in terms of elementary medical knowledge that we have to incorporate into the prevention, diagnosis, treatment and, above all, follow-up care of patients. That is what we have to learn. That is why I chose the expression "learning from the crisis", to show that we have to turn the situation into a positive one: This crisis is a lesson that we have to accept because it is there and it is so overwhelming, but we should also accept it because many new things emerge from it that are important for all of us. That is the purely medical part.

But in addition, through the change in healthcare systems that was forced upon us by the crisis, we have had many experiences that we should definitely take into account for the further design of health systems. Even before the crisis, there was the perception that a discrepancy exists between what we actually want to provide and what we can provide with the available resources. Now we have been forced by the crisis to reorganise entire service areas and it has suddenly become apparent how quickly everything can be done with common sense and good will, simply because the necessity is there. In the process, a lot of willingness to cooperate and flexibility has emerged, while contending issues have had to be pushed aside.

What is particularly important to me and what goes back to our original congress theme "Less is more" is something we must remember: We suddenly have a situation in which many services that we used to provide in large numbers, both inpatient and outpatient, are now being provided in much less frequencies. We absolutely have to try to learn what this means for patients: Is there harm done to patients because of this? Or are there specific services that perhaps would not have been necessary for them? We have to look at this in a creative way, but even before the COVID-19 crisis there was an extensive study of so-called "low-value medicine", i.e. medical provision of services that had a low value for the health of patients. Perhaps in the COVID-19 crisis we have managed to avoid these low-value measures in particular, without external guidance.

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