The Travel Clinic has been in the service of public health since its inception in the 1980s, but the focus is changing. Whereas in the past it was primarily concerned with the well-being of travelers from and to tropical countries, today the field is thought of more broadly, in terms of 'Global Health and Mobility'. The health of migrants is becoming an issue and due to global warming, it is also important for the local population in Switzerland to develop measures against tropical diseases.

We sat down with Prof. Dr. med. Jan Fehr, infectiologist and Head of Department of Public & Global Health at the Institute of Epidemiology, Biostatistics and Prevention at the University of Zurich.

In this second part we will talk about the emergence of travel medicine in Switzerland, how the current world situation affects the health of the individual and why the Swiss must care about the effects of their own behavior on the other side of the world, whether they want to or not - because the tropics are coming to us!

Dive into the dynamic world of travel medicine and find out why doctors must also be activists.

Haven't read the first part yet? Click here for the article.

We have talked about what Switzerland and its institutions can contribute to the world's major health issues. But let's come back to one of our missions here at the Department. You said at the beginning that you came here because many health issues are merging here, and together they can be productively developed into something new. But let's start at the beginning: What is travel medicine and why does it exist here in Switzerland?

Modern travel medicine was founded in Zurich in 1988. My predecessor, Prof. Robert Steffen^[1], convened the first travel medicine congress here together with the CDC^[2], thus pioneering something that was already in the air. Beginning in the 1970s, long-distance travel became increasingly affordable, which led to the emergence of mass tourism in the following decades. More people could afford to fly far away and their health in the sub-tropics and tropics became an issue.

However, an increase was not only seen in vacation travelers. Due to increased international trade, the share of business travelers also increased.

Are these the people you have started to take care of here?

Exactly, this is the classic travel medicine: preparation before departure, which includes malaria prophylaxis depending on the destination, travel vaccinations and boosters for the basic vaccinations (eg. the measles vaccination), as well as valuable tips on how else you can protect yourself. This preparation also includes information on what to do if you suddenly fall ill while traveling or after returning to Switzerland. All this goes beyond infectious diseases. For expedition travelers, altitude medicine or diving medicine may also be part of it. Because above 2500 m.a.s.l. there is a risk of altitude sickness.

However, new developments are rapidly emerging worldwide, which pose enormous challenges regarding health, both globally and individually. We must and want to react to this. This means that classical travel medicine must be thought of more broadly and expanded to towards “global health and mobility”. This gives us the opportunity to address issues related to public as well as global health.

This includes, for example, people who are not traveling because they want to, but because their living conditions or the political situation force them to leave their home country. In the future, we also want to take care of people who come to us from other regions of the world, especially from the global south. We're talking about “migrant health” here. We have already started to do this with the NIIDS^[3] study and we will continue to expand this. There is an emerging gap in care here. Based on the findings of studies and in close cooperation with those affected, we hope to be able to establish seamless medical care.

In the spirit of a lively university, close to the population, we want to find answers to important questions, implement what we have learned, and share our findings with other professionals. We call this “science to practice” and “science to policy”. This is what we want to live here.

So, in line with a more globally connected world, terms everywhere are changing in a more global and inclusive direction? From Public Health to Global Health, from Travel Medicine to Mobility Medicine?

Right. We, thus, allow ourselves a broader mindset. At this point, I would like to come back to the fact that not only humans, but also carriers of diseases (disease vectors) such as mosquitoes and pathogens are on the move. If climatic conditions change, these can then also establish themselves in Central Europe.

For example, the West Nile virus was discovered last year in August in a mosquito in Ticino for the first time. This virus originally comes from the West Nile region in Uganda and the disease that emerges from it was, thus, a classic tropical disease. It is only a matter of time before the first human case occurs here. I expect a first case in Switzerland this year. Germany already had the first case in Leipzig in 2019. In other words, the tropics are coming to us.

Another classic tropical disease is dengue. In recent years, for example, there have been repeated reports from the south of France of dengue cases in people who have not traveled.

As infectious diseases specialists and travel medicine specialists at the Travel Clinic, we closely monitor the spread of vectors and pathogens. We also think about measures against it. Similar to weather forecasting, the prediction of further developments will become more important in the coming years.

A question out of personal interest: How do you find a mosquito with West Nile Virus, just like that? Are they simply collected and tested from time to time?

The people of Ticino are exemplary here. They have set up a whole monitoring system. Incidentally, we also had tiger mosquitoes here in Wollishofen. They were found because traps were set up. Traps were also set up at the bus station near Zurich's main train station, where the Flixbuses depart. There is a cantonal office that takes care of this.

Now we would like to move on from the big concepts like One Health, Planetary Health, Global Health, which we discussed in the first part of the interview, to the individual and the focus of this part: Mobility and Health. Our topic this month is "Responsible Global Citizenship". What does this mean and why is it important?

In my opinion, the concept of a 'responsible global citizen' is based on the banal realization that we all live on the same planet and deal with it in such a way that both fellow citizens and the environment as well as future generations find a space worth living in.

How do you become a "Responsible World Citizen"?

First of all, you have to be interested in it - you are not indifferent towards how other people are doing, other living beings and the environment. And if we're talking about global health: you must want to face global health problems and deal with them.

You must realize that you can make a difference as an individual. You can actively think about every action you take in your everyday life. It starts when you get up in the morning. With the clothes you put on that you bought somewhere. You can think about where they were produced and under what conditions. That brings us back to the topic of equity. You can ask yourself how durable the clothes are and whether they produce microplastics. Then it's on to breakfast. You can question whether an avocado has to be on the plate or whether a fruit from the garden would also do it and maybe even taste better because it's just super fresh. You can perceive all these things, or not. A certain awareness, sensitivity and will are necessary.

So, you must take an interest, hold a mirror up to yourself and question everything. That sounds exhausting. How much responsibility can and should lie on the individual?

This is a philosophical question and there are certainly people who can answer it better than I can. But I can try to give an answer: I think it's a choice. Do we want to react to the current situation? Do we make the effort to react in time or do we close our eyes and just watch global warming happening until certain parts of the world are no longer habitable? By the way, this will trigger an enormous wave of migration and the climate will also become so unbalanced here that we will struggle with existential problems, from landslides and enormous drought to floods.

In the end, the earth does not need us and if you look at it from this point of view, then you might as well stop taking action. In the end you simply have to ask yourself what you want.

But the indicators are clear. The scientific community agrees. Global warming cannot be explained away, and, honestly, it is actually quite clear what needs to be done. Net Zero targets are being discussed everywhere. The big question is how to change behavior. How can this be achieved in everyday life? It's always nice if you can somehow do it in the form of an invitation to the public, and let the individual become part of a social movement that pursues a common goal. From Fridays for Future to “Climate Grandparents”, a foundation has been laid for this. When a movement then becomes a new social norm, we made it.

Is there an example of such a change which eventually became a new norm?

There were times when people still smoked in restaurants. Today, you can hardly imagine that. If you tried to reintroduce it today, everyone would shake their heads. In this way, certain social norms can be set, unwritten or even better written and, thus, institutionally anchored.

Ultimately, however, this is a discussion of values. Here we are deep in the social discussion: What is worth what? What do you stand up for, what do you spend money on, where do you invest time and energy? Do I take the time for sustainable travel and, where possible, take the train to distant countries, or do I always have to get to my destination as quickly as possible and decide to take the plane?

These are discussions that we must hold and where we are also required to show alternatives in our positions. And the alternatives must be attractive. Let's go back to the travel example: If train travel can be as uncomplicated and pleasant as possible in the future, the relaxation already begins at Zurich main station when the train departs. That this is not only the case in theory is shown by the trend of enormous demand for night trains, which are fully booked months in advance.

You mentioned the topic of travel - where do you see opportunities to reconcile 'responsible global citizenship' and long-distance travel with a large ecological footprint? Is this not a contradiction?

People will always travel or be on the road: voluntarily or because they have to. Those who do this voluntarily, e.g. as a vacation, can consider, for example, how often one really has to fly far away and also in which arrangement: Do I really want to go to Southeast Asia three times a year for a few days or would I rather go once a year for a little longer and really immerse myself in the culture there?

I believe that it can help if we as travelers plan our trips with an awareness of our ecological footprint. I call this sustainable travel - perhaps a little comparable to 'slow food' or indeed 'slow tourism'. This can also include thinking about what the situation is like for local workers in the tourism industry. Who gets how much of the money we spend on travels? How fairly is this distributed? And to what extent does this benefit the local population?

Certain offers are far too cheap which is in conflict with sustainability and social justice. In the future, we at the ZRM want to help support travelers who are concerned about sustainability.

I would like to take up the topic of the climate crisis again - how can we confront it?

There are basically two approaches: adaptation and mitigation. I believe we have to do both in our race against time.

On one hand, in terms of mitigation, we must try to get to the root of the problem and develop our living space in such a way that we contribute to achieving the Net Zero goals. Basel, for example, has taken on a pioneering role in this regard. Basel wants to have reached the Net Zero goal by 2037, and they are already fully on track.

On the other hand, we have to take immediate measures in the sense of adaptation, with constantly rising temperatures and increasing numbers of heat deaths in recent years. It is mainly the elderly who are affected. In summer, rooms must be made available where people can find shelter from the heat.

The bottom line of the whole story is that the problem cannot be addressed only top down or only bottom up, but everyone has their share of responsibility.

Exactly. The bottom line is: multi-approaches on multi-levels, trans- and interdisciplinary, because these are problems in large and complex systems that require complex solutions.

In conclusion: Why is this topic so close to your heart?

My career went differently than I had imagined. Actually, my career went wrong (he grins), because I always wanted to become a country doctor and work for the health of people in remote areas, including mountain rescue. This idea mixed well with my enthusiasm for the mountains. In the mountains I move on foot, on the rock, on the bike or on skis.

During my elective year of study, I worked for Dr. Bruno Durrer. At that time there were only two doctors in Switzerland who were also mountain guides. One of them was Bruno Durrer, who worked for Air-Glaciers, among others, and the other was Dr. Urs Wiget with Air Zermatt. That absolutely fascinated me.

We did helicopter rescues in the mountains. We had to jump up from lunch because an emergency call came in and the helicopter picked us up behind the practice on a short stop-over. I was told to take my skis with me because after the injured person was loaded, there was no room left for me as an assisting medical student. Bruno Durrer told me to simply turn up at the practice again later in the afternoon. Left behind somewhere out in nowhere, I then had to find my way back to the practice on my skis.

I was able to combine my hobby with my passion for caring for patients, my passion for their well-being. I thought that was great and that this was my future.

But it wasn't.

No, I belong to the generation that was enormously influenced by the topic of HIV/AIDS, and that's how I came to the field of infectious diseases. It was a huge challenge at that time, many people died. It was the era when the first drugs appeared, and something could be offered. I wanted to be there and contribute something.

In the course of time, I was getting comfortable with the idea of expanding the 'mountain rescue missions' to 'humanitarian missions' abroad. The idea was to participate in MSF^[5] missions as a medical doctor. Instead, I was given the opportunity to go to Ifakara in Tanzania as a trainee infectiologist sent by the Swiss TPH and the University Hospital Basel. The assignment for me as a young researcher was to conduct a study.

Thanks to the study findings, we were able to drastically reduce the infection rate after operations in the local hospital. This had an immediate effect for every single person and at the same time for the population in the region because we were able to improve something in the system. For the first time I understood what public health meant and at the same time saw this in the context of the global south.

This captivated me and Public Health, or rather Global Health, coupled with science and global responsibility, didn't let go of me until today. I saw that change is possible if we only want to work for it.

So you're actually an activist.

Probably yes. There is a beautiful phrase by Alex Coutinho, the former director of IDI^[6] . In an interview with the Tagesanzeiger he said: "Doctors must also be activists".

That's a wonderful conclusion. Thank you for your time, your commitment and this insightful conversation.

In the first part, Jan Fehr explained the complex issues the public health sector is facing, what it means to want to change huge systems, why healthcare must be thought of holistically, and why Switzerland is still in its infancy regarding prevention.

Come with us on a journey through the intertwined and fragile network of global health and explore with us the opportunities, but also the responsibility of small Switzerland in these global challenges. Click here for the article.

Interview: Cécile Rasi

^[1] Prof. em. Robert Steffen

^[2] Centers for Disease Control and Prevention: amerikanische Gesundheitsbehörde

^[3] Novel integrated infectious diseases diagnosis and surveillance system

^[4] Medienmitteilung Stadt Zürich, 2021

^[5] Responsible Global Citizenship: «Verantwortungsvolle Weltbürgerschaft”

^[6] Ärzte ohne Grenzen

^[7] Schweizerisches Tropen- und Public-Health-Institut

^[8] Infectious Diseases Institute