Doctors have been observing for years that climate change causes or exacerbates certain medical conditions. However, the health care system itself is putting a heavy burden on the environment. At the Institute of General Medicine, students learn how sustainable medicine works.

By Anna Euteneuer

Opposite Cologne’s ‘Gürtel’, beyond the large university hospital, is its Outpatient Clinic for General Medicine at Gleueler Straße 176–178. Taking the lift to the 3rd floor, visitors are welcomed in a bright, friendly room with modern facilities. At first glance, the furnishings do not appear to be what they in fact are: second-hand. Although new institutes receive money for equipment, Professor Dr Beate Müller did not want to invest this in new furniture. Instead, the head of the university outpatient clinic procured lockers, cabinets, examination tables and chairs from the university hospital’s warehouse. Some of the medical devices are refurbed. And instead of buying new crockery for the staff kitchen, all employees brought cups, plates and cutlery from home.

Beate Müller’s vision for the future of general medicine is sustainability. For her, this is not limited to furnishings, recycling and energy saving. Climate change already affects our health today. Heat, for example, poses a risk particularly for elderly people. For this group, staying hydrated is just as important as adjusting the dosage of medication, since sweating and increased blood circulation to the skin can cause drugs to lose their effect or to have a different effect.
 

An 81-percent increase in skin cancer
 

In addition to the outpatient clinic, Müller also heads the Institute of General Medicine of the Faculty of Medicine, which was newly founded in April 2022. This means that her week is filled with patient care, courses, research projects and management tasks. “I am very concerned by the effects of climate change,” the physician said. Therefore, she focuses on the topic not only in her practice, but also in her teaching, drawing students’ attention to the various health consequences of climate change. According to her, “almost every medical condition is affected in some way by climate change.” 
 

Illness caused by heat and the sun directly spring to mind: Dehydration or skin cancer are responsible for more and more deaths in Germany. Today, 81 percent more patients with skin cancer are hospitalized compared to 2000. Also, many more diseases can be linked to global warming. Last year, the University of Hawaii published a review study that found that nearly 60 percent of pathogen-induced diseases are exacerbated by climate change. These include not only viruses, but also bacteria, fungi and plant pollen. Heat and warmth, but also floods, promote the spread of pathogens such as bacteria or diseases transmitted by mosquitoes and ticks. Allergy sufferers are also already feeling the effects of climate change: A study from the USA shows that in 2018, compared to 1990, the pollen season not only started twenty days earlier, but also lasted ten days longer and the pollen concentration has increased by 20 percent. 

“What I want is for climate change to be a topic in every general medical course,” Müller explained. “Not that the entire lecture has to revolve round the topic, but when we talk about coughing, for example, I mention that joggers are better off in the park than on the street.”  That way, she hopes to raise students' awareness of climate change and its health effects without pontificating.

Drugs cause species to die out

Professor Müller is also so committed to sustainability because she has two children and wants to assume responsibility towards the next generation. Also, it helps her to deal with the topic in a constructive way. As a teacher and institute director, she has the opportunity to raise awareness among prospective doctors. 

A little-known aspect is the influence of certain drugs on the environment. They are one of the most important factors that can affect GP practices. The production of many drugs is energy-consuming. What is even worse, however, is their application or disposal. Asthma sprays are problematic due to the gas cartridge. Luckily, a powder is available as a less harmful alternative. Just as there are deodorant roll-ons as an alternative to aerosol spray cans.

Another issue is the effects certain agents can have on flora and fauna. “Diclofenac, for example, is a problematic substance,” Müller said. The pain-relieving gel is available without prescription up to a certain dosage. General practitioners often do not even know that patients are using the ointment.

What hardly anyone knows: Diclofenac has led to vultures in India almost becoming extinct, which is why there is still the highest rate of rabies in humans there. In India, cattle were treated with diclofenac for joint problems in order to maintain their working capacity. When these animals died, vultures came to eat the carcass. However, diclofenac is as toxic to vultures as potassium cyanide is to humans. The vultures died of kidney failure and wild dogs then took care of the carcass. In consequence, their population exploded. Since these dogs often suffered from rabies, their spread also led to a higher rate of rabies among humans. 

The case of vultures in India has been known for about ten years. In 2020, a dead vulture with diclofenac poisoning was also found in Europe. It takes a long time and is difficult to identify such cycles. “It is not yet foreseeable how many other active substances are toxic to the environment and what problems we will get,” the doctor warned.
Diclofenac is also problematic because it cannot be filtered out of the water by sewage treatment plants without expensive and complex processes. Pharmacies and medical practitioners therefore recommend that people do not wash their hands after applying the gel, but rather wipe them clean and dispose of the cloth in the waste basket. 

Small adjustments make a big difference

There are many small behavioural changes that can have a big impact on our environment. Beate Müller tries to implement as many factors as possible and pass them on to the next generation of medical professionals. Under the direction of the Institute of General Medicine, a Planetary Health Report Card for the Faculty of Medicine has been compiled. The grade: C-. Compared to other universities in the Rhineland, however, this result is not too bad. Other universities are in the range of grade D.  Since teaching has a major impact on the overall outcome of the Planetary Health Report Card, the University has benefited from Müller's commitment. 

Planetary Health Report Card – The metric-based instrument was developed by medical students at the University of California San Francisco (UCSF) in 2019. Since then, it has served students worldwide in evaluating their universities in the field of ‘planetary health’. Students fill out the report card in teams and with the guidance of teachers and identify opportunities for improvement. The results are published in an annual Earth Day report with the goal of making institutional changes comprehensible over time.

In addition, research and sustainability on campus are evaluated. There is still great potential here, but the university is already taking first steps with the Sustainability Forum, among other things. Research on the topic of ‘Planetary Health’ has started at the Institute of General Medicine, and some research groups and clinical departments are committed to sustainable work. 

Sustainability Forum – The first Sustainability Forum of the University and the University Hospital took place on 9 February. About 250 people from all areas came together to gain information, network and develop plans for a sustainable transformation. From this Event a digital poster gallery as well as the lecture by Professor Müller are available.

Sustainability in medicine includes many practical tips on the adaptability of medical practices to climate change. On hot days, the consultation hours could be adjusted to when it is less hot. According to Müller, more information on the use of medications is needed in order to keep the environmental impacts as low as possible. Or on the small things that the practice team can take do every day. Like turning off the equipment completely and not operating in standby mode, or reminding patients not to dispose of medication in the toilet or sink. And even personal behaviour can help make at least a small contribution. Like Beate Müller: “To save electricity and for my own health, I prefer to take the stairs rather than the lift.”