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climate change&#44; ecosystem degradation&#44; loss of biodiversity&#44; and the depletion of natural resources&#46; On 15 November 2022&#44; the world population reached 8 billion people&#46; Since 1970&#44; our ecological footprint has exceeded the rate of regeneration of the planet Earth&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The effects of climate change include global warming&#44; extreme temperatures&#44; food shortages&#44; increased allergens&#44; loss of biodiversity&#44; more severe storms&#44; floods&#44; fires&#44; and droughts&#44; more poverty&#44; displacement&#44; and health risks&#46; It is estimated that climate change could take over 100 million people into extreme poverty by 2030&#46; The <span class="elsevierStyleItalic">World Meteorological Organization</span> and the Copernicus program have confirmed that July 2023 was the hottest month ever recorded&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In 2023&#44; in Canada&#44; a forest area equivalent to 17 million football fields was consumed by fire&#46; With the current policies&#44; the planet will exceed the 1&#46;5&#8239;&#176;C limit set by the Paris Agreement&#44; and it is estimated that this increase could reach 2&#46;7&#8239;&#176;C by 2100 - though the complexity of the ongoing phenomena and the existence of tipping points may make this prediction uncertain&#46; These changes are attributable to the past and future greenhouse gas emissions&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Human activities have contributed to the growing destruction of forests&#44; grasslands and wetlands&#44; threatening people&#8217;s lives and well-being&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Food production is not only affected by climate change&#44; but is also responsible for 20&#37; to 30&#37; of greenhouse gases&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> At present&#44; 55 million people are suffering from drought&#44; and it is estimated that 75&#37; of the world population could be affected by 2050&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> On average&#44; 150 species become extinct each day&#44; and one million species are at risk of extinction&#46; &#40;2&#41;</p><p id="par0020" class="elsevierStylePara elsevierViewall">These changes&#44; to which the health sector also contributes&#44; are having a devastating impact on population health&#46; This document expresses the consensus of 32 societies&#44; colleges and associations of Internal Medicine in 29 Spanish- and Portuguese-speaking countries on the priorities in the participation of internists and health professionals&#44; in general&#44; in actions to adapt and mitigate this impact&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Given the importance of the effects of climate change on the environment and&#44; above all&#44; on human health&#44; and the essential and fundamental role played by Internal Medicine in this emerging problem&#44; a working group was set up in July 2023 with representatives of the 32 scientific societies&#44; colleges and associations of Internal Medicine from 29 Spanish- and Portuguese-speaking countries&#46; The main objective was to develop a consensus document to make this situation visible and to outline strategies to combat this urgent problem&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The secondary objectives were to promote the prevention of the possible consequences of climate change&#59; to encourage specific training and research in this area&#44; and to take measures to combat threats to our health systems and their sustainability resulting from climate change&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">For the development of this document&#44; a non-systematic literature review was performed by the members of the working group&#44; selecting recent articles &#40;published in the last two years&#41; and some of special relevance from previous years&#46; The search period ended in August 2023&#46; The document was prepared through virtual meetings held in the last week of August&#46; A two-round DELPHI method was used to build consensus&#44; involving all collaborators from the different countries&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Experts&#44; collaborators&#44; and representatives of the scientific societies&#44; colleges&#44; and associations involved in the preparation of this international consensus document are listed in Appendix 1&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">The recommendations for healthcare professionals resulting from this consensus are presented below&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Ethical obligations&#58;</span> It is our ethical duty to participate in the global fight against climate change and environmental degradation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Cooperation of health organizations&#58;</span> Health organizations must work together to reduce the health impact of environmental change on the human population&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Environmental sustainability practices&#58;</span> We must develop and implement good environmental sustainability practices at all levels to reduce the ecological footprint of the health system&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Clinical guidelines&#58;</span> Clinical guidelines for the prevention and management of the health consequences of environmental change should be published&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Public awareness&#58;</span> We have to commit ourselves to raising public awareness of these issues&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Education on <span class="elsevierStyleItalic">One Health&#58;</span></span> Education on <span class="elsevierStyleItalic">One Health</span> must be mandatory in the pre- and post-graduate training of healthcare professionals&#44; and should be incorporated into scientific meetings&#46; Research in this field should be encouraged and supported&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Climatic resilience&#58;</span> Health systems should be resilient to climate change and develop capabilities to respond to the current epidemiological transition and the increased risk of unexpected events&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Prevention of inequalities&#58;</span> We must actively prevent inequalities referred to the health consequences of environmental change and protect the most vulnerable populations&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9</span><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Exemplary behavior&#58;</span> We must be an example of environmentally friendly behaviors&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10</span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Role of Internal Medicine&#58;</span> Internal Medicine must be defended as a core specialty for responding to the health consequences of environmental change&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Each year&#44; environmental factors cause about 13 million deaths or 20&#37; of overall mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Globally&#44; 9 out of 10 people breathe air with high levels of pollutants exceeding the limits set by the WHO&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Air pollution and increased allergen levels are driving the growth in the incidence of cardio- and cerebrovascular diseases&#44; lung cancer&#44; chronic obstructive pulmonary disease&#44; asthma&#44; and allergies&#46; With the changes in vector ecology&#44; vector-borne diseases are on the rise&#44; causing more than 700&#44;000 deaths a year&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Zoonoses are growing&#44; and account for almost 100&#37; of all pandemics&#46; Water-related diseases cause more than 3&#46;4 million deaths annually&#44; and food-borne diseases cause 420&#44;000 deaths a year&#44; overall&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Climate&#44; weather&#44; and water hazards have accounted for 50&#37; of all disasters and 45&#37; of all reported deaths since 1970&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> More than 10 million people died because of the severe droughts of the last century and&#44; each year&#44; &#62;5 million additional deaths can be attributed to extreme temperatures&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> Climate change is having stronger and more lasting impacts on people&#44; with direct and indirect damage to their mental health and psychosocial well-being&#46; These consequences particularly affect the most vulnerable populations&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">On the other hand&#44; health systems must increase climate resilience and their environmental sustainability&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In 2020&#44; the WHO published a framework for implementing climate resilience and environmental sustainability in health facilities&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> This document highlights four key requirements&#58; the existence of an adequate number of qualified human resources with decent working conditions&#44; and those who are ready to respond to these environmental challenges&#59; sustainable and safe management of water&#44; sanitation and waste services&#59; sustainable energy services&#59; and efficient infrastructure&#44; technologies&#44; products and processes&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Beyond human resources&#44; to address this epidemiological transition and the increased risk of climate catastrophes&#44; health systems must have emergency plans at all levels of care&#59; hospitals must be flexible&#44; scalable&#44; and with matrix-based organization&#59; different levels of care must be integrated&#59; there must be a sufficient number of hospital beds and intensive care beds&#59; information and communication systems must be robust&#59; telemedicine must be facilitated to reduce patient travel&#59; health care disparities must be prevented&#59; and political decisions must be accompanied by science&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Internists were at the forefront of the response to the COVID-19 pandemic&#44; due to their broad training&#44; polyvalence&#44; efficiency&#44; and coordination capacity&#46; General internal medicine is undoubtedly a crucial medical specialty for addressing the uncertainty that threatens our health systems&#44; particularly in hospitals&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Although the health system is essential to respond to epidemiological change and the increased risk of unexpected events&#44; it is also responsible for 4&#46;4&#37; of greenhouse gas emissions&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Reducing the ecological footprint of the health sector requires a strategy at the national level and has to be seen as a political priority&#46; Everyone&#44; at every level of decision&#44; is urged to contribute&#46; Many of these measures may imply short-term investments&#44; but they generate important medium- and long-term savings&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Health systems&#44; through demands placed on their providers&#44; can also have an indirect influence in many other sectors&#46; In the United Kingdom&#44; the NHS &#40;National Health Service&#41; has set itself a target of zero emissions by 2040&#44; in everything directly dependent upon it&#44; and by 2045&#44; in everything indirectly dependent on it&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Several scientific societies have already taken positions calling for greater involvement of healthcare professionals in this effort&#46; The European Federation of Internal Medicine also published a position paper&#44; calling for the same&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Health professionals have an unavoidable responsibility for this emerging problem&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The sense of the duty of intergenerational solidarity and the notion that doctors&#44; in addition to carer providers&#44; should also be advocates for our patients&#44; must be our motivation to be involved in the fight against climate change&#44; environmental degradation&#44; and its consequences for the health of the population&#46; We as physicians&#44; and health professionals&#44; have an ethical obligation to participate in this global movement&#46; We do not have the right to ensure our well-being at the expense of the next generations&#44; which are the generations of our children and our grandchildren&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">It is not the survival of the planet or even life that is threatened&#44; but that of many species&#44; including us humans&#46; Robert Swan&#44; the first man to reach both poles&#44; said&#58; &#8220;The biggest threat to our planet is the belief that someone else will save it&#46;&#8221; Changing the announced fate for humanity requires everyone&#8217;s commitment&#44; and health professionals have an additional responsibility in this fight&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Facing the severity of the impact of climate change and environmental degradation on human health&#44; 32 Internal Medicine societies&#44; colleges&#44; and associations of 29 Spanish and Portuguese-speaking countries issue a consensus document in which they call for the implication of doctors and all health professionals in the global fight against the causes of these changes&#46; This commitment requires the cooperation of health-related organizations&#44; elaboration and implementation of good environmental sustainability practices&#44; greater awareness of professionals and population&#44; promotion of education and research in this area&#44; increasing climate resilience and environmental sustainability of health systems&#44; combating inequalities and protecting the most vulnerable populations&#44; adopting behaviors that protect the environment&#44; and claiming Internal Medicine as a core specialty for empowerment of the health system to respond to these challenges&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ante la gravedad del impacto sobre la salud del cambio clim&#225;tico y la degradaci&#243;n ambiental 32 sociedades&#44; colegios&#44; y asociaciones de Medicina Interna de 29 pa&#237;ses de habla hispana y lusa divulgan un documento de consenso en que llaman a la implicaci&#243;n de los m&#233;dicos y todos los profesionales de salud en la lucha global contra las causas de estos cambios&#46; Este compromiso requiere la cooperaci&#243;n de las organizaciones relacionadas con la salud&#44; elaboraci&#243;n e implementaci&#243;n de buenas pr&#225;cticas de sostenibilidad ambiental&#44; sensibilizaci&#243;n de los profesionales de la salud y de la poblaci&#243;n&#44; promoci&#243;n de la educaci&#243;n e investigaci&#243;n en esta &#225;rea&#44; refuerzo de la resiliencia clim&#225;tica y la sostenibilidad ambiental de los sistemas de salud&#44; combatir las desigualdades y proteger a las poblaciones m&#225;s vulnerables&#44; adopci&#243;n de comportamientos que protegen el medio ambiente&#44; y defensa de la Medicina Interna como una especialidad central para habilitar al sistema de salud para responder a estos desaf&#237;os&#46;</p></span>"
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            "apendice" => "<p id="par0175" class="elsevierStylePara elsevierViewall">Andrea Fiabane-Salas &#40;Sociedad Chilena de Medicina Interna&#41;</p> <p id="par0180" class="elsevierStylePara elsevierViewall">Ant&#243;nio Carlos Lopes &#40;Sociedade Brasileira de Cl&#237;nica M&#233;dica&#41;</p> <p id="par0185" class="elsevierStylePara elsevierViewall">Bismarck Perez &#40;Asociaci&#243;n Nicarag&#252;ense de Medicina Interna&#41;</p> <p id="par0190" class="elsevierStylePara elsevierViewall">Carlos Araya-Fonseca &#40;Sociedad de Medicina Interna de Costa Rica&#41;</p> <p id="par0195" class="elsevierStylePara elsevierViewall">Carlos W&#46; Contreras-Camarena &#40;Sociedad Peruana de Medicina Interna&#41;</p> <p id="par0200" class="elsevierStylePara elsevierViewall">Claudia Arias &#40;Asociaci&#243;n de Medicina Interna de Centroam&#233;rica y El Caribe&#41;</p> <p id="par0205" class="elsevierStylePara elsevierViewall">Diego Alberto Brosio &#40;Sociedad Argentina de Medicina&#41;</p> <p id="par0210" class="elsevierStylePara elsevierViewall">Diego Gra&#241;a-Cruz &#40;Sociedad de Medicina Interna de Uruguay&#41;</p> <p id="par0215" class="elsevierStylePara elsevierViewall">Emilio F&#46; Buchaca-Faxas &#40;Sociedad Cubana de Medicina Interna&#41;</p> <p id="par0220" class="elsevierStylePara elsevierViewall">Evelyn Murillo &#40;Sociedad Cruce&#241;a de Medicina Interna - Bolivia&#41;</p> <p id="par0225" class="elsevierStylePara elsevierViewall">Fortuna Peralta &#40;Sociedad de Medicina Interna de Republica Dominicana&#41;</p> <p id="par0230" class="elsevierStylePara elsevierViewall">Helga Codina &#40;Sociedad Hondure&#241;a de Medicina Interna&#41;</p> <p id="par0235" class="elsevierStylePara elsevierViewall">Jo&#227;o Francisco Pascoal &#40;Col&#233;gio de Especialidade de Medicina Interna da Ordem dos M&#233;dicos de Angola&#41;</p> <p id="par0240" class="elsevierStylePara elsevierViewall">Jos&#233; Javier Arango-Alvarez &#40;Asociaci&#243;n Colombiana de Medicina Interna&#41;</p> <p id="par0245" class="elsevierStylePara elsevierViewall">Jes&#250;s Falc&#243;n &#40;Sociedad Paraguaya de Medicina Interna&#41;</p> <p id="par0250" class="elsevierStylePara elsevierViewall">Jorge Rafael Soto-Castillo &#40;Sociedad de Medicina Interna de la Rep&#250;blica Dominicana&#41;</p> <p id="par0255" class="elsevierStylePara elsevierViewall">Juan L&#46; Salgado-Loza &#40;Colegio de Medicina Interna de M&#233;xico&#41;</p> <p id="par0260" class="elsevierStylePara elsevierViewall">Karen Elizabeth C&#225;rcamo de Villatoro &#40;Asociaci&#243;n de Medicina Interna de El Salvador&#41;</p> <p id="par0265" class="elsevierStylePara elsevierViewall">Ligia Maria M&#46; D&#46; Almeida &#40;Col&#233;gio de Especialidade de Medicina Interna da Ordem dos M&#233;dicos Caboverdianos&#41;</p> <p id="par0270" class="elsevierStylePara elsevierViewall">Liza Matlombe &#40;Col&#233;gio de Medicina Interna da Ordem dos M&#233;dicos de Mo&#231;ambique&#41;</p> <p id="par0275" class="elsevierStylePara elsevierViewall">Maria Luc&#237;a Fortuna de Galarza &#40;Asociaci&#243;n Dominicana de M&#233;dicos Internistas&#41;</p> <p id="par0280" class="elsevierStylePara elsevierViewall">Mariflor Vera &#40;Sociedad Venezolana de Medicina Interna&#41;</p> <p id="par0285" class="elsevierStylePara elsevierViewall">M&#225;rio &#201;vora &#40;Associa&#231;&#227;o de M&#233;dicos de L&#237;ngua Portuguesa de Macau&#41;</p> <p id="par0290" class="elsevierStylePara elsevierViewall">Mayra Cifuentes &#40;Asociaci&#243;n de Medicina Interna de Guatemala&#41;</p> <p id="par0295" class="elsevierStylePara elsevierViewall">Meno Nabicassa &#40;Ordem dos M&#233;dicos da Guin&#233;-Bissau&#41;</p> <p id="par0300" class="elsevierStylePara elsevierViewall">Natalie Maynard Gamboa &#40;Asociaci&#243;n Costarricense de Medicina Interna&#41;</p> <p id="par0305" class="elsevierStylePara elsevierViewall">Omar Castillo-Fernandez &#40;Sociedad Paname&#241;a de Medicina Interna&#41;</p> <p id="par0310" class="elsevierStylePara elsevierViewall">Ricardo Hidalgo Ottolenghi &#40;Asociaci&#243;n Ecuatoriana de Medicina Interna&#41;</p>"
            "etiqueta" => "Appendix 1"
            "titulo" => "Collaborators representing the societies&#44; colleges and national associations of Internal Medicine signing this consensus document"
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Special article
Recommendations of the Spanish-Portuguese Internal Medicine services in the fight against climate change and environmental degradation
Recomendaciones de los servicios de Medicina Interna hispano-lusos en la lucha contra el cambio climático y la degradación ambiental
L. Camposa,
Corresponding author
luis.campos@cpsa.pt

Corresponding author.
, M.M. Chimeno-Viñasb, J. Carretero-Gómezc, L. Santosd, A. Cabrera-Rayoe, P.R. Valdezf, R. Gómez-Huelgasg, en nombre de las sociedades, colegios, y asociaciones de Medicina Interna de los países de habla hispana y lusa
a Portuguese Council for Health and Environment, Hospital CUF Tejo, Lisbon, Portugal
b Spanish Society of Internal Medicine, Complejo Asistencial de Zamora, Zamora, Spain
c Spanish Society of Internal Medicine, Hospital Universitario de Badajoz, Universidad de Extremadura, Badajoz, Spain
d Portuguese Society of Internal Medicine, Centro Hospitalar Universitário de Coimbra, Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
e Global Summit of Internal Medicine, Instituto Mexicano del Seguro Social, México, Ciudad de México, México
f International Forum of Internal Medicine, Hospital Vélez Sarsfield, Univesidad de Buenos Aires, Buenos Aires, Argentina
g European Federation of Internal Medicine, Hospital Regional Universitario de Málaga, Universidad de Málaga, Málaga, Spain
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climate change&#44; ecosystem degradation&#44; loss of biodiversity&#44; and the depletion of natural resources&#46; On 15 November 2022&#44; the world population reached 8 billion people&#46; Since 1970&#44; our ecological footprint has exceeded the rate of regeneration of the planet Earth&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The effects of climate change include global warming&#44; extreme temperatures&#44; food shortages&#44; increased allergens&#44; loss of biodiversity&#44; more severe storms&#44; floods&#44; fires&#44; and droughts&#44; more poverty&#44; displacement&#44; and health risks&#46; It is estimated that climate change could take over 100 million people into extreme poverty by 2030&#46; The <span class="elsevierStyleItalic">World Meteorological Organization</span> and the Copernicus program have confirmed that July 2023 was the hottest month ever recorded&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In 2023&#44; in Canada&#44; a forest area equivalent to 17 million football fields was consumed by fire&#46; With the current policies&#44; the planet will exceed the 1&#46;5&#8239;&#176;C limit set by the Paris Agreement&#44; and it is estimated that this increase could reach 2&#46;7&#8239;&#176;C by 2100 - though the complexity of the ongoing phenomena and the existence of tipping points may make this prediction uncertain&#46; These changes are attributable to the past and future greenhouse gas emissions&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Human activities have contributed to the growing destruction of forests&#44; grasslands and wetlands&#44; threatening people&#8217;s lives and well-being&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Food production is not only affected by climate change&#44; but is also responsible for 20&#37; to 30&#37; of greenhouse gases&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> At present&#44; 55 million people are suffering from drought&#44; and it is estimated that 75&#37; of the world population could be affected by 2050&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> On average&#44; 150 species become extinct each day&#44; and one million species are at risk of extinction&#46; &#40;2&#41;</p><p id="par0020" class="elsevierStylePara elsevierViewall">These changes&#44; to which the health sector also contributes&#44; are having a devastating impact on population health&#46; This document expresses the consensus of 32 societies&#44; colleges and associations of Internal Medicine in 29 Spanish- and Portuguese-speaking countries on the priorities in the participation of internists and health professionals&#44; in general&#44; in actions to adapt and mitigate this impact&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Given the importance of the effects of climate change on the environment and&#44; above all&#44; on human health&#44; and the essential and fundamental role played by Internal Medicine in this emerging problem&#44; a working group was set up in July 2023 with representatives of the 32 scientific societies&#44; colleges and associations of Internal Medicine from 29 Spanish- and Portuguese-speaking countries&#46; The main objective was to develop a consensus document to make this situation visible and to outline strategies to combat this urgent problem&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The secondary objectives were to promote the prevention of the possible consequences of climate change&#59; to encourage specific training and research in this area&#44; and to take measures to combat threats to our health systems and their sustainability resulting from climate change&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">For the development of this document&#44; a non-systematic literature review was performed by the members of the working group&#44; selecting recent articles &#40;published in the last two years&#41; and some of special relevance from previous years&#46; The search period ended in August 2023&#46; The document was prepared through virtual meetings held in the last week of August&#46; A two-round DELPHI method was used to build consensus&#44; involving all collaborators from the different countries&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Experts&#44; collaborators&#44; and representatives of the scientific societies&#44; colleges&#44; and associations involved in the preparation of this international consensus document are listed in Appendix 1&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">The recommendations for healthcare professionals resulting from this consensus are presented below&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Ethical obligations&#58;</span> It is our ethical duty to participate in the global fight against climate change and environmental degradation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Cooperation of health organizations&#58;</span> Health organizations must work together to reduce the health impact of environmental change on the human population&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Environmental sustainability practices&#58;</span> We must develop and implement good environmental sustainability practices at all levels to reduce the ecological footprint of the health system&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Clinical guidelines&#58;</span> Clinical guidelines for the prevention and management of the health consequences of environmental change should be published&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Public awareness&#58;</span> We have to commit ourselves to raising public awareness of these issues&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Education on <span class="elsevierStyleItalic">One Health&#58;</span></span> Education on <span class="elsevierStyleItalic">One Health</span> must be mandatory in the pre- and post-graduate training of healthcare professionals&#44; and should be incorporated into scientific meetings&#46; Research in this field should be encouraged and supported&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Climatic resilience&#58;</span> Health systems should be resilient to climate change and develop capabilities to respond to the current epidemiological transition and the increased risk of unexpected events&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Prevention of inequalities&#58;</span> We must actively prevent inequalities referred to the health consequences of environmental change and protect the most vulnerable populations&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9</span><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Exemplary behavior&#58;</span> We must be an example of environmentally friendly behaviors&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10</span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Role of Internal Medicine&#58;</span> Internal Medicine must be defended as a core specialty for responding to the health consequences of environmental change&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Each year&#44; environmental factors cause about 13 million deaths or 20&#37; of overall mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Globally&#44; 9 out of 10 people breathe air with high levels of pollutants exceeding the limits set by the WHO&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Air pollution and increased allergen levels are driving the growth in the incidence of cardio- and cerebrovascular diseases&#44; lung cancer&#44; chronic obstructive pulmonary disease&#44; asthma&#44; and allergies&#46; With the changes in vector ecology&#44; vector-borne diseases are on the rise&#44; causing more than 700&#44;000 deaths a year&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Zoonoses are growing&#44; and account for almost 100&#37; of all pandemics&#46; Water-related diseases cause more than 3&#46;4 million deaths annually&#44; and food-borne diseases cause 420&#44;000 deaths a year&#44; overall&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Climate&#44; weather&#44; and water hazards have accounted for 50&#37; of all disasters and 45&#37; of all reported deaths since 1970&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> More than 10 million people died because of the severe droughts of the last century and&#44; each year&#44; &#62;5 million additional deaths can be attributed to extreme temperatures&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> Climate change is having stronger and more lasting impacts on people&#44; with direct and indirect damage to their mental health and psychosocial well-being&#46; These consequences particularly affect the most vulnerable populations&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">On the other hand&#44; health systems must increase climate resilience and their environmental sustainability&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In 2020&#44; the WHO published a framework for implementing climate resilience and environmental sustainability in health facilities&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> This document highlights four key requirements&#58; the existence of an adequate number of qualified human resources with decent working conditions&#44; and those who are ready to respond to these environmental challenges&#59; sustainable and safe management of water&#44; sanitation and waste services&#59; sustainable energy services&#59; and efficient infrastructure&#44; technologies&#44; products and processes&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Beyond human resources&#44; to address this epidemiological transition and the increased risk of climate catastrophes&#44; health systems must have emergency plans at all levels of care&#59; hospitals must be flexible&#44; scalable&#44; and with matrix-based organization&#59; different levels of care must be integrated&#59; there must be a sufficient number of hospital beds and intensive care beds&#59; information and communication systems must be robust&#59; telemedicine must be facilitated to reduce patient travel&#59; health care disparities must be prevented&#59; and political decisions must be accompanied by science&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Internists were at the forefront of the response to the COVID-19 pandemic&#44; due to their broad training&#44; polyvalence&#44; efficiency&#44; and coordination capacity&#46; General internal medicine is undoubtedly a crucial medical specialty for addressing the uncertainty that threatens our health systems&#44; particularly in hospitals&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Although the health system is essential to respond to epidemiological change and the increased risk of unexpected events&#44; it is also responsible for 4&#46;4&#37; of greenhouse gas emissions&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Reducing the ecological footprint of the health sector requires a strategy at the national level and has to be seen as a political priority&#46; Everyone&#44; at every level of decision&#44; is urged to contribute&#46; Many of these measures may imply short-term investments&#44; but they generate important medium- and long-term savings&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Health systems&#44; through demands placed on their providers&#44; can also have an indirect influence in many other sectors&#46; In the United Kingdom&#44; the NHS &#40;National Health Service&#41; has set itself a target of zero emissions by 2040&#44; in everything directly dependent upon it&#44; and by 2045&#44; in everything indirectly dependent on it&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Several scientific societies have already taken positions calling for greater involvement of healthcare professionals in this effort&#46; The European Federation of Internal Medicine also published a position paper&#44; calling for the same&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Health professionals have an unavoidable responsibility for this emerging problem&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The sense of the duty of intergenerational solidarity and the notion that doctors&#44; in addition to carer providers&#44; should also be advocates for our patients&#44; must be our motivation to be involved in the fight against climate change&#44; environmental degradation&#44; and its consequences for the health of the population&#46; We as physicians&#44; and health professionals&#44; have an ethical obligation to participate in this global movement&#46; We do not have the right to ensure our well-being at the expense of the next generations&#44; which are the generations of our children and our grandchildren&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">It is not the survival of the planet or even life that is threatened&#44; but that of many species&#44; including us humans&#46; Robert Swan&#44; the first man to reach both poles&#44; said&#58; &#8220;The biggest threat to our planet is the belief that someone else will save it&#46;&#8221; Changing the announced fate for humanity requires everyone&#8217;s commitment&#44; and health professionals have an additional responsibility in this fight&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Facing the severity of the impact of climate change and environmental degradation on human health&#44; 32 Internal Medicine societies&#44; colleges&#44; and associations of 29 Spanish and Portuguese-speaking countries issue a consensus document in which they call for the implication of doctors and all health professionals in the global fight against the causes of these changes&#46; This commitment requires the cooperation of health-related organizations&#44; elaboration and implementation of good environmental sustainability practices&#44; greater awareness of professionals and population&#44; promotion of education and research in this area&#44; increasing climate resilience and environmental sustainability of health systems&#44; combating inequalities and protecting the most vulnerable populations&#44; adopting behaviors that protect the environment&#44; and claiming Internal Medicine as a core specialty for empowerment of the health system to respond to these challenges&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ante la gravedad del impacto sobre la salud del cambio clim&#225;tico y la degradaci&#243;n ambiental 32 sociedades&#44; colegios&#44; y asociaciones de Medicina Interna de 29 pa&#237;ses de habla hispana y lusa divulgan un documento de consenso en que llaman a la implicaci&#243;n de los m&#233;dicos y todos los profesionales de salud en la lucha global contra las causas de estos cambios&#46; Este compromiso requiere la cooperaci&#243;n de las organizaciones relacionadas con la salud&#44; elaboraci&#243;n e implementaci&#243;n de buenas pr&#225;cticas de sostenibilidad ambiental&#44; sensibilizaci&#243;n de los profesionales de la salud y de la poblaci&#243;n&#44; promoci&#243;n de la educaci&#243;n e investigaci&#243;n en esta &#225;rea&#44; refuerzo de la resiliencia clim&#225;tica y la sostenibilidad ambiental de los sistemas de salud&#44; combatir las desigualdades y proteger a las poblaciones m&#225;s vulnerables&#44; adopci&#243;n de comportamientos que protegen el medio ambiente&#44; y defensa de la Medicina Interna como una especialidad central para habilitar al sistema de salud para responder a estos desaf&#237;os&#46;</p></span>"
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            "apendice" => "<p id="par0175" class="elsevierStylePara elsevierViewall">Andrea Fiabane-Salas &#40;Sociedad Chilena de Medicina Interna&#41;</p> <p id="par0180" class="elsevierStylePara elsevierViewall">Ant&#243;nio Carlos Lopes &#40;Sociedade Brasileira de Cl&#237;nica M&#233;dica&#41;</p> <p id="par0185" class="elsevierStylePara elsevierViewall">Bismarck Perez &#40;Asociaci&#243;n Nicarag&#252;ense de Medicina Interna&#41;</p> <p id="par0190" class="elsevierStylePara elsevierViewall">Carlos Araya-Fonseca &#40;Sociedad de Medicina Interna de Costa Rica&#41;</p> <p id="par0195" class="elsevierStylePara elsevierViewall">Carlos W&#46; Contreras-Camarena &#40;Sociedad Peruana de Medicina Interna&#41;</p> <p id="par0200" class="elsevierStylePara elsevierViewall">Claudia Arias &#40;Asociaci&#243;n de Medicina Interna de Centroam&#233;rica y El Caribe&#41;</p> <p id="par0205" class="elsevierStylePara elsevierViewall">Diego Alberto Brosio &#40;Sociedad Argentina de Medicina&#41;</p> <p id="par0210" class="elsevierStylePara elsevierViewall">Diego Gra&#241;a-Cruz &#40;Sociedad de Medicina Interna de Uruguay&#41;</p> <p id="par0215" class="elsevierStylePara elsevierViewall">Emilio F&#46; Buchaca-Faxas &#40;Sociedad Cubana de Medicina Interna&#41;</p> <p id="par0220" class="elsevierStylePara elsevierViewall">Evelyn Murillo &#40;Sociedad Cruce&#241;a de Medicina Interna - Bolivia&#41;</p> <p id="par0225" class="elsevierStylePara elsevierViewall">Fortuna Peralta &#40;Sociedad de Medicina Interna de Republica Dominicana&#41;</p> <p id="par0230" class="elsevierStylePara elsevierViewall">Helga Codina &#40;Sociedad Hondure&#241;a de Medicina Interna&#41;</p> <p id="par0235" class="elsevierStylePara elsevierViewall">Jo&#227;o Francisco Pascoal &#40;Col&#233;gio de Especialidade de Medicina Interna da Ordem dos M&#233;dicos de Angola&#41;</p> <p id="par0240" class="elsevierStylePara elsevierViewall">Jos&#233; Javier Arango-Alvarez &#40;Asociaci&#243;n Colombiana de Medicina Interna&#41;</p> <p id="par0245" class="elsevierStylePara elsevierViewall">Jes&#250;s Falc&#243;n &#40;Sociedad Paraguaya de Medicina Interna&#41;</p> <p id="par0250" class="elsevierStylePara elsevierViewall">Jorge Rafael Soto-Castillo &#40;Sociedad de Medicina Interna de la Rep&#250;blica Dominicana&#41;</p> <p id="par0255" class="elsevierStylePara elsevierViewall">Juan L&#46; Salgado-Loza &#40;Colegio de Medicina Interna de M&#233;xico&#41;</p> <p id="par0260" class="elsevierStylePara elsevierViewall">Karen Elizabeth C&#225;rcamo de Villatoro &#40;Asociaci&#243;n de Medicina Interna de El Salvador&#41;</p> <p id="par0265" class="elsevierStylePara elsevierViewall">Ligia Maria M&#46; D&#46; Almeida &#40;Col&#233;gio de Especialidade de Medicina Interna da Ordem dos M&#233;dicos Caboverdianos&#41;</p> <p id="par0270" class="elsevierStylePara elsevierViewall">Liza Matlombe &#40;Col&#233;gio de Medicina Interna da Ordem dos M&#233;dicos de Mo&#231;ambique&#41;</p> <p id="par0275" class="elsevierStylePara elsevierViewall">Maria Luc&#237;a Fortuna de Galarza &#40;Asociaci&#243;n Dominicana de M&#233;dicos Internistas&#41;</p> <p id="par0280" class="elsevierStylePara elsevierViewall">Mariflor Vera &#40;Sociedad Venezolana de Medicina Interna&#41;</p> <p id="par0285" class="elsevierStylePara elsevierViewall">M&#225;rio &#201;vora &#40;Associa&#231;&#227;o de M&#233;dicos de L&#237;ngua Portuguesa de Macau&#41;</p> <p id="par0290" class="elsevierStylePara elsevierViewall">Mayra Cifuentes &#40;Asociaci&#243;n de Medicina Interna de Guatemala&#41;</p> <p id="par0295" class="elsevierStylePara elsevierViewall">Meno Nabicassa &#40;Ordem dos M&#233;dicos da Guin&#233;-Bissau&#41;</p> <p id="par0300" class="elsevierStylePara elsevierViewall">Natalie Maynard Gamboa &#40;Asociaci&#243;n Costarricense de Medicina Interna&#41;</p> <p id="par0305" class="elsevierStylePara elsevierViewall">Omar Castillo-Fernandez &#40;Sociedad Paname&#241;a de Medicina Interna&#41;</p> <p id="par0310" class="elsevierStylePara elsevierViewall">Ricardo Hidalgo Ottolenghi &#40;Asociaci&#243;n Ecuatoriana de Medicina Interna&#41;</p>"
            "etiqueta" => "Appendix 1"
            "titulo" => "Collaborators representing the societies&#44; colleges and national associations of Internal Medicine signing this consensus document"
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            "etiqueta" => "Appendix 2"
            "titulo" => "Societies&#44; colleges and national associations of Internal Medicine signing this consensus document"
            "identificador" => "sec0045"
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                  "referenciaCompleta" => "Food and Agriculture of the United Nations&#46; Joint Tripartite &#40;FAO&#44; OIE&#44; WHO&#41; and UNEP Statement Tripartite and UNEP support OHHLEP&#8217;s definition of &#8220;One Health&#8221;&#46; &#91;accessed 23 Jul 2023&#93; Available from&#58; <a target="_blank" href="https://www.fao.org/3/cb7869en/cb7869en.pdf">https&#58;&#47;&#47;www&#46;fao&#46;org&#47;3&#47;cb7869en&#47;cb7869en&#46;pdf</a>&#46;"
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ISSN: 22548874
Original language: English
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