 Welcome to this webinar hosted by the Sustainable Development Solutions Network and the Centre for Sustainable Development. Osge Karadag, please you may begin. Thank you. Good morning, good afternoon and good evening. Welcome to our event where we will be sharing key findings of the Mental Health Task Force of the Lancet COVID-19 Commission and policy recommendations regarding population groups with different vulnerabilities. During the acute phase of the pandemic, the mental health task force focused on the mental and neurological consequences of the pandemic and policies to decrease mental health inequalities caused by the pandemic. The task force was chaired by Dr. Lara Akne and 16 distinguished experts from around the world have contributed. I also would like to mention that the publications of the task force can be found on the Commission's website. I now would like to give the floor to Dr. Lara Akne who chaired the Mental Health Task Force to open the event and to present the first paper of the task force. Thank you Osge. Hi everyone, my name is Lara Akne and I had the pleasure of serving as the chair for the Lancet's COVID-19 Mental Health Task Force. And today I'd like to tell you about our first report titled Mental Health during the first year of the COVID-19 pandemic, a review and recommendations for moving forward. At the time of writing our first report, the novel coronavirus had already infected millions of people and altered the lives of nearly every human on the planet. Although early fears focused on respiratory failure from contracting the virus, a fast growing body of research pointed to the possibility that COVID-19 had a farther reaching impact than originally recognized. Specifically during the first year of the pandemic, most of the world's population lived with the uncertainty of contracting the virus and with disruptions to daily life resulting from public health measures implemented to slow the spread of COVID-19, which may have imposed psychological challenges. What were and are the mental health consequences of living through a pandemic? What can be done to support mental health during a pandemic and beyond? To address these questions, we assembled as the Lancet's Mental Health Task Force to consider the available evidence at the time and offer research grounded suggestions for the future. Today I'll be sharing the insights and recommendations from the first report. Before proceeding, I'd like to clarify how we defined mental health in our review. We focused on four relevant constructs that had been sufficiently studied at the time during the pandemic to provide robust information. First, we explored psychological distress, which captures a range of psychological states. We focused primarily on representative constructs such as anxiety, depression and distress. Second, we examined self-harming behavior, which we defined as the deliberate and direct destruction or alteration of body tissue that results in damage. We also considered suicidal ideation and suicide attempts. While self-harming behavior is not a component of mental health, it is a maladaptive method of coping with negative emotions. Third, we considered subjective well-being, which we defined as the extent to which someone reports experiencing a preponderance of positive affect or emotions and infrequent negative affect and emotions, as well as a positive evaluation of their life. And finally, we examined loneliness, which is a state associated with self-reported deficiencies in one's social relationships. Although loneliness itself is not a facet of mental health, research indicates that loneliness is a key predictor of mental health challenges such as distress. So with these definitions in mind, how did mental health change during the first year of COVID-19? We posed three questions. First, how did average levels of mental health change from pre-pandemic to during the pandemic? Second, which factors predicted greater risk or protection in mental health during the pandemic onset and early months? And third, what were the correlates of better or worse mental health after the pandemic had started? Today, I'll focus on insights gleaned in respect to question one and briefly cover highlights of questions two and three. Finally, I'll share our recommendations to support mental health during the pandemic and beyond. So how did mental health change under COVID? A clear and consistent body of evidence suggests that psychological distress increased during the early months of COVID-19. For instance, a comparison of cross-sectional nationally representative panels in the U.S. showed a three-fold increase in depression and four-fold increase in the percentage of people reporting symptoms from severe psychological distress. However, on most metrics of distress, we saw declining levels to pre-pandemic levels by mid-2020. In fact, a meta-analysis of 65 studies reported a significant increase in both anxiety and depression from March to April 2020, but then a decline or return to near pre-pandemic levels on most measures except depression by that summer. Meanwhile, data on self-harm was more mixed. Some evidence suggests that thoughts of self-harm and suicide increased in some places but not others. Yet several longitudinal data sets suggested that change, there was little change or even a decline in self-harming behavior during the early months of COVID-19. For instance, researchers analyzing real-time suicide data from government sources in 21 countries using some very sophisticated analyses found no evidence for increases in suicide from April through July 2020 when comparing the observed rates to expected rates. In fact, suicide rates were significantly lower than model expectations in some countries and regions during this timeframe. For subjective well-being, people experienced more unpleasant emotions during the pandemic than before. Interestingly, life satisfaction ratings remained largely unchanged in most large-scale international data sets. And finally, evidence concerning loneliness and social connection showed some notable signs of resilience. Despite early speculation and fear that physical distancing would unleash an epidemic of loneliness, repeated cross-sectional studies found little evidence for substantial change. Now the data I've presented so far offers some insight into the big picture changes in mental health by looking at mean levels in large populations. This approach is valuable, but it also masks some significant variation in who had been impacted the most. So we looked at longitudinal data sets assessing the four measures of mental health that I mentioned earlier, among the same individuals before and during the early months of COVID-19, to see how various factors such as age, gender and socioeconomic status predicted changes over time as the pandemic substantially altered daily life. These data provide some insight into some predictors of mental health, whether they remain the same, or whether new predictors of mental health or struggle emerged. Now for the sake of time, I'll focus on two mental health facets with the largest evidence pools to draw upon that also happen to provide some consistent insights for these are psychological distress and self-harm. Now what impressive investigation found and is consistent with others. I did found that people who identify as female who are members of minority or marginalized racial groups who live in urban as opposed to rural areas who are in the lowest income quintiles, or who are unemployed, who live alone, or who have a preexisting health risk reported higher levels of psychological distress under COVID. Now many of these predictors were similar to what we had seen before COVID-19 suggesting that many of the usual risks remained. However, additional evidence underscored new profiles of risk as well. Specifically, it seems that individuals who identified as female who were younger or who had young children under the age of five at home reported steeper inclines for psychological distress during the pandemic, suggesting that some risk factors remain from for COVID and new risk profiles were introduced. Turning to our final question regarding what experiences and behaviors were associated with better or worse or worse mental health during COVID. One clear correlate of lower mental health, mainly psychological distress and self-harm was believing that you or a close other had contracted COVID. Another important predictor of lower mental health during COVID was financial scarcity or strain imposed by the, by the pandemic. Finally, several behaviors were associated with higher or lower psychological distress and wellbeing during the pandemic. Specifically, time spent gardening or in nature, exercising, reading or listening to music predicted decreases in depression. Taking while spending more time following COVID-19 news predicted lower mental health on nearly all measures. And finally, a number of papers reported a negative association between mental health and time spent engaging in childcare, homeschooling and chores. In light of these central findings, our task force proposed seven research grounded recommendations to help governments, businesses and individuals support mental health during the pandemic and beyond. The next agenda will be considering and expanding on these shortly, I believe, taking them into further consideration, but here I'd like to quickly name them for all of you and you can follow our paper for a deeper discussion. So the first is that we support immediate large scale research into the nature treatment and long-term consequences of COVID-19 on mental health. The second is that we screen and monitor mental health among COVID-19 survivors close relations and those with greater exposure or risk and burden of care. The third is to prioritize safe access to childcare and elementary schooling. The fourth is to invest in mental health care so that someone with mental illness has equal access to evidence based treatment as someone with physical illnesses. Number five is to tailor the mental health resources to what are available. This should include online and in person follow ups to support ongoing treatment. Number six is to supplement existing mental health care with well being promotion to take a proactive approach. Number seven is to facilitate access to mental health care and well being promotion alongside social care so that people who are in need do not need to go out of their way to seek out these supports, but that it is woven into the everyday fabric of our lives. We hope this review calls greater attention to the acute and long term needs for supporting mental health during the pandemic and beyond, and you can access a full copy of our paper online or by emailing me. Thank you. Thank you so much, Dr admin. Before I invite the next speaker, I would like to invite our participants to share their questions and our comments in the Q&A box of the screen. Now I would like to give the floor to Dr Alcanon Goldberg to briefly present the second paper of the task force which was on neurological consequences. Dr Goldberg I think you're muted. Hello. So, indeed, as the previous speaker has said, even though COVID-19 was initially characterized as a respiratory illness, which of course it is. It didn't take long for us to understand that it also has multiple and profound neurological and neurocognitive ramifications. Okay. So above and beyond the secondary psychological manifestation that were alluded to earlier. So the brain was directly impacted. And it was directly impacted by several mechanisms that both direct impact of the virus on the brain via the so called rapid external transport. The virus would enter the nasal cavity and then latch on. And there is some controversy as the exact mechanisms. But for our purpose, if that's not that important latch on to the all factor in nerve and then enter the brain. It would produce damage in certain distinct parts of the brain in the frontal lobes and in the temporal lobes. And these anatomical consequences are of kind of a direct the direct consequence in a variety of ways because it allows us to these lesions are permanent lesions to the extent that these lesions were incurred. They were there to stay. These were not reversible lesions. And they allowed us to make certain predictions about about the consequent cognitive impairment. So this impact of the virus direct impact of the virus on the brain basically resulted probably in the situation whereby these patients would end up with significant memory impairment and significant what we call executive impairment in other words impulse control decision making and so forth. And to the extent that these lesions are permanent. One could expect that these cognitive ramifications would also be long term and possibly even permanent. Okay, so this is one mechanism. The other mechanism in direct in effect an autoimmune response when the virus would trigger vigorous immune response which is a good thing. But then what would happen is too much of a good thing and the immune response would go over into overdrive and impact the brain in maladaptive ways. And that resulted in its own range of very unusual consequences like ischemic stroke ischemic stroke in young people usually ischemic stroke to the to the extent that it takes place. It's kind of the melody of older people. Here we began to see large numbers of people in their 40s and even 30s who suffered from ischemic stroke. And what was particularly unusual is that many of them had multiple strokes virtually simultaneously. And of course this too leads to permanent long term and very often permanent brain damage was all the consequence. Of course, there were some ramifications know also hemorrhagic stroke inflammation of the brain. We began to encounter patients who who continue to exhibit inflammation of the brain several months after the resolution of the acute episode. And in our own work week demonstrated this phenomenon three months after the resolution of the acute episode, but then the other research suggested that it may continue even much longer, at least six months after the resolution of acute episode. So it's probably it's chronic inflammation of the brain. And again, we don't know it's probably highly valuable for how much longer it can persist, but probably for a long time. Okay. And this is probably one of the mechanisms underlying this mysterious long neuro COVID when people, when people find themselves that saddled with cognitive impairment which has led them catastrophic, but debilitating on an ongoing basis, this brain fog, people continue to live and very often continue to continue to work, but then a cognitively diminished state. So this this this the chronic brain inflammation is probably one of those mechanisms. And, and just to go back to what I said earlier, and in addition to that, there are these other phenomena, which lead to truly catastrophic kind of a truly debilitating consequences like my ischemic stroke in a large artery that will render you may cognitive for the rest of your life. And so this is one of the consequences which will have to contend. And then there was another thing, which at this point is somewhat more conjectural, more speculative, but there is a growing reason to believe that that the exposure to COVID may put you at increased risk for developing various neurodegenerative conditions later in life. Okay. Some of this evidence basically or indirect evidence has been around for many, many years, even before, before the current pandemic, because coronavirus, this novel coronavirus is what it is. It's a novel coronavirus, but it's a member of a family of ours, which has been known and has been around for many years. And many of these so called corona viruses were regarded benign. But it turned out that when the levels antibody levels to these ostensibly benign coronaviruses were measured in the cerebrospinal fluid of patients with multiple sclerosis patients with patients with Parkinson's disease, it turned out that there were abnormally elevated What does that mean? That means that exposure to these ostensibly benign coronaviruses probably were a risk factor in the development of Parkinson's disease of multiple sclerosis and any number of other neurodegenerative diseases. Okay. And if these ostensibly mild corona, benign coronaviruses could do that, then it only stands to reason that this much more kind of a severe impactful novel coronavirus SARS-CoV-2 that's, you know, behind the current pandemic could do it also. And indeed we have a handful of observations, handful of reports when people were exposed to this novel coronavirus developed COVID-19 and then developed something akin to Parkinson's disease. And whereas, you know, generally Parkinson's disease is a very slowly developing condition it takes years for these symptoms to accumulate. In this case, there was this whole process was compressed in a matter of a few days. So they acquired this whole panoply of symptoms, which we see in patients with Parkinson's disease in the course of a few days, maybe a week. Okay. So there is a relatively direct reason to suspect that exposure to this massage cough to may result in subsequent development of Parkinson's disease. And of course today we know that Parkinson's disease is not just a movement disorder. It is a movement disorder. But now we are finding out that it's also cognitive disorder. So these patients are at risk for developing cognitive impairment in addition to tremors and other forms of movement impairment. And there is some evidence coming from animal studies where monkeys were exposed to novel coronavirus. It was found that in their brain there was a proliferation of Lewy bodies. Lewy bodies are macroscopic pathological entities, which are basically the cause of Lewy body dementia. So and you know, the basic biology is basically the same across all primates. So to the extent that it was demonstrated in these macaque monkeys, it's probably applicable to humans as well. All right. So there are multiple reasons to suspect that exposure to coronaviruses will put one at substantial risk for developing any number of neurodegenerative disorders later in life. That remains a conjecture. And hopefully we are wrong in making this prediction because, you know, we'll have to wait X number of years and follow these patients in order to find out whether it will indeed happen or not. All right. So, but there is this whole panoply of long term and very long term and potentially permanent and neurological and neurocognitive impairments, which one can expect, expect even beyond the resolution of acute episode. Right. Well, what does that mean? That means that we should be prepared that that we should be prepared to to to be faced with large number of people with neurological and neurocognitive impairment of a very long term nature. And we'll require and this is an arena for for psychologists for neuropsychologists and other kinds of psychologists and other mental health professionals to step in and make a definitive contribution. They will require counseling. They will require therapy and they will require various forms of neurodegenerative mutations. So this is the challenge to challenge to create these structures and these systems which would enable us to follow to identify these patients to to to follow them on a very long term basis and to provide some services to these people. I mean, in the beginning of the pandemic, everybody was preoccupied, preoccupied with kind of the life threatening aspects of this illness and was life saving aspects of treatment. Okay, now we're beyond that point. And so now the society has both the kind of the knowledge and the sophistication and the luxury to deal with these less than direct life threatening conditions, but nonetheless catastrophic conditions involving cognition and cognitive impairment. And you know, nothing is entirely new in the world. What we're facing with now is uncannily similar to what we encountered a few decades ago was HIV. Okay, when which was initially HIV and cephalopathy, HIV epidemics, which was initially labeled as the viral illness, attacking, attacking the immune system and which it did, but then it didn't take long for us to find out that it's also affected the brain. And that we had to deal with HIV and cephalopathy. So now we're encountering a similar situation, and we should be better prepared to deal with these non respiratory in a color neurological and neuro cognitive modifications of this illness. So this is the challenge for all of us. All right. Thank you so much. Thank you, Dr. Goldberg for sharing these very interesting findings. And now I would like to give the floor to Dr. Rafael Goldsmith, and Dr. John Hellowell to present the third paper of the task force. I also would like to remind our participants that they can share their questions and comments in the Q&A box. So please, Dr. Rafael. This paper discusses the impacts of the pandemic on mental health and fits in the literature that was presented before by Professor Lara, and that has extensively studied this issue, and what we contribute goes into two different dimensions. One of them is we try to disentangle how much of the changes in mental health that are observed during the pandemic are associated with pandemic policy itself with all the closures and restrictions to gatherings and so on and so forth that had impacts possibly on restriction of social connections and disruption of habits. And how much the presence of the pandemic itself, the sheer fact that people see that others are dying, that cases are growing, and that there is an important public health risk might be affecting mental health. So one dimension is try to disentangle effects of pandemic policy, containment policies, and the pandemic itself. And the other is to go beyond just looking at the association between policy stringency and mental health, but try to compare different pandemic strategies to try to look a little bit more into detailing how countries have dealt with the pandemic and how the timing and the type of policies that we used might have differential effects on mental health. And for that, we combine different sources of data. So we use to evaluate the association between policies stringency and mental health. The stringency index from the Oxford coronavirus government response tracker as a measure of the intensity of containment policies. And to measure our outcomes of interest, we use data from the ICL you go observing, which gather responses from more than 400 individuals from 15 countries in the periods in which you analyze the data between April 2020 and June 2021. And to the here to different measures well being as measured by the country ladder and psychological distress with the PHQ for scale. We have a set of controls in all this analysis, importantly, pandemic intensity, as measured by cases per 100 K and deaths per 100 K, and a set of individual level demographic controls, as well as vaccination rates. All the analysis with this data is considering fixed effects models with fixed country fixed effects, which means that we are interested in observing how our dynamics of association between the variables evolve over time within countries, rather than comparing different countries. In the companion analysis, we focus on pandemic strategies. And here we define two broad strategies, the elimination approach in which countries try to eliminate their community transmission of the virus. This was attempted by very early, early and targeted action, particularly with intense contact tracing and testing. On the other hand, the mitigation strategy did not pursue that goal, and the purpose was to try to control the impacts of the virus, once it was circulating and that was done through repeated reductions and increases in containment policies, following the different waves. So we have two ways of defining, of identifying countries that adopted these approaches. So one of them is considering the countries that belong to the World Health Organization Western Pacific Region as eliminators. The rationale behind that is that these countries had previous experience with SARS and hence were more prepared and more likely to try to adopt an elimination approach. In our sample, we had Australia, Japan, Singapore and South Korea as examples of eliminators. All other countries were classified as mitigators. One problem with this classification is that these two groups of countries are very different in many dimensions besides the pandemic strategy which could include several confounds. For that reason, we considered second grouping, looking only into Nordic countries which share many similarities, for instance, in terms of their public health infrastructure. And then we compared Sweden as a well-known case of a mitigator that didn't try to eliminate the community transmission of the virus, compared to the other Nordic countries in our sample, for instance, Denmark, Finland and Norway. Hence having one comparison that had way less confounders than the previous group. And when we look into some characteristics of the evolution of critical outcomes during the pandemic across mitigators and eliminators, we observe very stark differences. For instance, in this picture in the upper panel, we can see the number of daily deaths over the course of the pandemic and we have in blue, the mitigator countries and in red, the eliminator countries. What we can see is that mitigators had a much higher number of deaths during the period. And interestingly, when we compare the stringency index or the level of closures and containment policies that was adopted across eliminator and mitigator countries. What we find is that the red line representing the eliminators is practically all the time below the blue line, showing that eliminator countries needed less containment, less policy stringency than mitigators. And that was possible because the early targeted action reduced the transmission of the virus to a level in which later lockdowns were not necessary. And when we look into the results of our analysis of association. We observe that there is a positive association between psychological distress and policies stringency and the negative association between life evaluations and policies changes. So both results suggest that there's a detrimental effects of policies stringency on mental health. And two important points have to be clarified here. One of them is about the magnitude of these associations. So, for instance, the change in life evaluation comparatively from the lowest level of policies stringency observed in the period to the highest level is only one fifth of what it's observed after the loss of a job. So in relative terms, this is a small effect. Another important thing is if we look here at the coefficient highlighted in red, which is the association between pandemic intensity, number of deaths per hundred K, and psychological distress and life evaluation. We see that it is slightly higher than the association with policies stringency, which means the sheer fact that people know that there are others dying from the pandemic and that there is an important pandemic issue for public health around also harms mental health. And while current policies stringency is negatively associated with mental health, increasing stringency policies stringency today may reduce deaths in the future, and that in turn will support mental health. So over time, there are cumulative effects of policies stringency that become less negative for mental health. And finally, when we compare the groups of eliminators and mitigators, we see that eliminators fair better in many dimensions. Here we can see that the number of deaths per hundred K was much smaller, much smaller for eliminators than for mitigators. The eliminators needed less policies stringency than mitigators. And when we look at the changes in life evaluations from the pre pandemic period to the end of our analysis, we see that the drop in life evaluations was much smaller for eliminators than mitigators. And finally, this is recognized by how people evaluate government action with a better evaluation of government activity during the pandemic for people in countries that adopted elimination strategies than those that adopted mitigation strategies. One important point to keep in mind about the results of this analysis is that it goes only until June 2021. That is before the more transmissible omicron variants appeared, and while vaccination rates were still quite low. So now we will explore a little bit what has happened in more recent periods. And for that, I give the floor to Professor John Halliwell. Thank you, Rafa. The groups of countries shown here are the same we looked at before. So we've got the eliminators group of four on the left than the Nordic countries without Sweden and Sweden, then the rest of Western Europe and then Canada because it is the only country that's not in. It is in the 15 but is not in any of the other groups listed. You'll see that 2021 have quite similar pictures with clearly a preference for the eliminators over the mitigators. You can see in 2022 that the game is completely changed by Omicron. Now it isn't just Omicron. Omicron itself is feeding back to influence the strategies adopted by the previous eliminator countries. In almost all cases they are now mitigator countries in part because it became increasingly difficult to avoid community transmission under the very much higher transmissibility of the Omicron variant. And secondly, the costs of disease for those infected were reduced by the great prevalence of vaccination and some evidence that in fact the lethality and morbidity effects of Omicron were less than some of the earlier variants. So you'll see in the period for 2022 which is until a few days ago that the difference between country groups has almost disappeared. In other words, the number of these are deaths not cases. If you we looked at cases, the difference would be even more because as I suggested, the number of cases has grown by more than the number of deaths, to an extent, which is not even measured because the actual tracking of cases is now very much less. So that raises a question. If you say, remember our study only looked at the first 15 months. What does the eliminator strategy look like from the whole history of the three years with the eliminators simply storing up problems that would arise when the variant became more transmissible and the elimination strategies became more expensive or even unusable. Or did they in fact carry forward a net benefit from those first two years of gains into the third year where most places in the world were essentially facing the same risks and the same consequences. So this slide will bring those two bits together. And here you'll see cumulative COVID-19 deaths. And so this is asking ourselves, did the eliminators in general do better than the mitigators, looking at all three years together. And the answer is quite clearly. So the eliminators at about 50 deaths per 100K, the Nordics excluding Sweden about 100, Sweden about 200 other Western Europe, about 225 Canada down more or less at the Nordic level excluding Sweden. So that's our summary measure that in fact the earlier evidence we presented is not obsolete. It's a bankable gain that in fact has not been lost in that are buried by the subsequent much greater quality of results. In summary, I think we have a summary slide that is very brief indeed, is that originally the mental health effects which we measured were not very large. What dramatically we showed of course was that in fact, even though those negative effects were there, the eliminator countries in fact faced fewer of them than the mitigator countries. So what was thought to be a trade-off between mental health and disease control in fact with the right strategy was not a trade-off at all, that the timely and effective use of tracking and tracing and other controls permitted those countries to have less stringency and fewer deaths which of course as Rafa's evidence already suggested gave them fewer deaths and better mental health. And that is our story. Many thanks to Dr. Goldschmidt and Dr. Halliwell for their very interesting presentation. Now I would like to invite Dr. Shekhar Saxena to talk about the policy implications of the task force findings. Thank you Gave. It's a pleasure to join this discussion. Every Lancet Commission needs to have policy implications. If it does not have then it's unlikely to be a Lancet Commission and it applies equally well to the mental health task force. I will present very briefly a few policy implications which are directly emanating from the work that you have just now heard from the three papers as well as subsequent work which has been briefly reviewed by some of the presenters. And these remember are policy implications and not policy recommendations because that requires more discussion and that also requires contextualization to the individual countries. So the first policy implication which is very broad is that the work has reinforced the need to look at mental health as a dimension and not as a binary. It is clear even before COVID but it has become even more clear now based on the findings of the papers as well as other literature that has accumulated over this period of time. So the policy implications need to look at mental health as a dimension, as a spectrum and not divide the world arbitrarily into a group of people who have mental disorders and others who don't because all of us are affected to a smaller or a larger degree and something can be done about the mental health of all of us. So the first one is that COVID-19 as well as any future pandemics and in fact many humanitarian emergencies. And the control policies for these must take into account the mental health and subjective well being aspects and not exclude these from the policies that are being made. And as was very clear in the initial months the whole focus was on deaths and disabilities and not on mental health conditions and the logical conditions that needs to change. We need to put keep these in mind right from day one as the control policies start. The third implication is that resilience during crises need to be appreciated and enhanced by policies and practice. Resilience is a concept that is extremely important also for well being and these need to be kept in mind but also studied through cycles of pandemics and other humanitarian emergencies over time. This science is still somewhat immature so there is much more need for work but these need to be kept in mind as we decide on policies and practices. The fourth implication is that policies must be directed towards protecting the vulnerable segments of society and of course those could vary from pandemic to pandemic. In this case you heard that it was youth. The initial impression was that the old people who are going to be affected more. They did that get affected more because of physical disabilities and deaths but it was a young people who were much more affected by mental health consequences. Women, parents of young children and those who were economically impacted and these need to be kept in mind as we begin the response to any of the pandemics. And we need to initially study them and provide clear and concrete support which could be psychosocial, could also be economic. The fifth implication is related to brain and you just now heard about the kind of problems, small problems but also big problems. Short lasting problems as well as long lasting problems which could arise because of COVID-19. And certainly the implication is that brain needs to be kept in mind and at least in a minority of cases this can be severe and long standing. Neurological and mental health consequences should be counted in contributing to the overall burden caused by any disease including COVID-19. And studied longitudinally so that we can learn more and do more. Monitoring these aspects is essential during the pandemic but also after it. It was made very clear so that we have information which can guide our actions over longer periods of time. The sixth implication is about determinants of mental health and well-being including policy stringency which you just now heard about in the paper three. But we also know that the relationship is complex so there is no clear one policy guidance that could be given. Overall more stringent policies were associated with poor mental health but factors like severity of the epidemic, public information and trust in the government are critical variables. So national frameworks for policies must to account these factors and reassess dynamically. Things will change and the policies must change and all of that needs to be decided at a country level and no clear international one guidance is possible based basically on variable realities and the dynamic nature of the pandemic as it evolved. The seventh implication is greater coordination between various arms of the government is needed to more efficiently respond to mental health impact of the pandemic. And this needs to extend also to non-government stakeholders including businesses which will be the right way to go. These stakeholders need to be involved and policies need to be interdepartmental inter ministerial and perhaps guided from the top level of the government. Lastly, in view of the current severe deficiency in access to mental health services, and I must specify in high middle and low resource situation. And countries were still facing a lot of deficiency of services and will continue to face that strengthening of mental health system must be a global priority and it's very clear also from the WTO action plan which was accepted by all countries. More resources need to be allocated, but also must be utilized wisely just throwing money on the problem is unlikely to solve the problem with a good balance between protection promotion prevention and care for those who will need it. I propose these as policies implications for further discussion in this webinar but also subsequently, and of course for more research so that we can learn much more than we know now. Thank you very much for giving me this chance. Thank you very much, Dr. Saxena. Now I would like to give the floor to Dr. Sarah Jones to moderate the Q&A part. Thank you, thank you. Thank you to all of our presenters thank you to the members of the panel and to everyone attending. And please, I'd like to encourage the attendees to pose a question if they'd like to into the chat into the Q&A box. It's been illuminating not only to review where we were pre vaccination which thank goodness seems quite a long time ago for many of us, but also what we've learned since then. I'd like to open up a Q&A, actually with a comment from Jean, who is an attendee that I'd like to pose as a question, maybe to check our first and then I'd love to hear from the other panelists on this. How important is it to urge governments and organizations to do needs assessments and to measure mental health. Now I know that the mental health Atlas is has been a very important fixture in the global mental health community in terms of a benchmark. It's not something that we see happening every day. How important is it to do do these kinds of needs assessments and also this kind of measurement on a global coordinated level. Thanks Sarah and thanks for the question. Very important and I did refer briefly to it in one of the implications which was on monitoring. But yes, I can expand upon that there is need for a much better monitoring of the situation at a country level, but also at an international level. At country level we know that even in high income countries the needs are much higher than the availability of resources and it's certainly quite a catastrophe in majority of low and middle income countries. And of course, pandemics like like COVID-19 will increase the need and will actually decrease, we have seen it very clearly, decrease the availability and access to services so the gap does increase markedly. So there is need for a baseline assessment, but also there is need for any of the of the crisis situations like COVID-19 as they begin to continuously monitor the need. And also identify as I was saying earlier, vulnerable groups which will require much more action than the overall community. And all of these need to be built into the system nationally and internationally. And I would just like to mention that there is a project that is going on which is called Countdown Global Mental Health 2013, which actually does precisely that to monitor the situation for the determinants of mental health as well as the access to care in all countries and put it on a portal very transparently. So you can actually go to this portal and look at these these figures and then these figures can be quite useful for governments to improve their actions, but also for advocates to press for more action, and they can compare different countries, different timelines and so on. So yes, very important question and very important thing to do actually. Let me pose a sort of similar and related question maybe Alkanon I can ask you this first. When it comes to this measuring of mental health and happening, perhaps at a population level. How can that best be translated that information as quickly as possible into the clinical side. In pretty obvious ways I mean we're dealing with a range of neurocognitive neurocognitive problems. I mean there are people with memory impairment people was impairment of attention, people was executive deficit, the result of these various forms of brain damage. So, my concern is, and I'm kind of among the older among the, among the panelists have very good memories of HIV encephalopathy and I was involved in in that work also how you know it was recognized as a disease affecting the immune system which it did. But then it was also recognized that it had neuro neurocognitive neurological implication, but that was given a short shift. It was a rhetorically recognized, but but not much effort was made to read this picture. These issues is kind of a systematically institutionally and my, I hope that that will not happen with with COVID, which also initially was recognized as a respiratory, you know, to hammer everything is a nail. The HIV was in the hands of infectious disease doctors. COVID today is also in the hands of infectious disease doctors. They do they, they are interested in what they understand and what they know. You see what I'm saying, from their standpoint, cognition mental health is, is a side show is peripheral. They'll always recognize it territorially, but not necessarily never you kind of a well internalized fashion. So we must make sure that it's not given a short shift in terms of government policies in terms of fund allocation, because there will be huge numbers of people with with cognitive impairment. A friend of mine, Adam Hampshire at Imperial College in England, they conducted a population study. Do you know him? Yeah, you're raising your hand. They conducted a population study and basically calculated quantitatively that if all these events relatively modest cognitive losses per per capita, so to speak, then multiplied by the number of people affected, we're talking basically we're talking about kind of a cognitive disability of a medium sized country. So the cumulative effect will be huge. So it's very important to to bring this point home that mental health in terms of the secondary effects like depression like anxiety, but also direct effects of brain damage, like cognitive impairments due to chronic brain inflammation, due to ischemic stroke in young people. I mean, it's one thing when an ischemic stroke happens to somebody who's 70 years of age. You know, he that person had a good life up to that point. Okay, it's another thing when it happens to a 30 year old, then basically the whole life is ruined. So there are degrees of cognitive impairment, ranging from from significant but less than total life destroying like in this kind of a mental fog to to those which truly destroy lives like ischemic stroke in major arteries. And so these are issues which need to be recognized. And then there is this issue of increased risk for dementia maybe X number of years later. And as I said, there is a relatively direct evident that these people may be at risk for Parkinson's disease, Lewy body disease and of course we know that Parkinson's and Lewy body is more or less the same thing today. There are also reasons to suspect that they may be at risk for Alzheimer's disease. So at this point it's a conjecture because we need to wait X number of years until this threat either materializes or doesn't materialize. There's a very distinction or something in between right, but but in order to deal with that cogently, we need to say to put in place some mechanisms to some registers to follow these people. And that's very methodologically daunting and financially expensive. So there will be some kind of a resistance to that, and it needs to be overcome. And this system need to be put in place now. Absolutely. Thank you for that. John, I might direct this one to you. Would you care to speculate about why the experience under Oberkram was so different than under the earlier variants for the eliminator versus mitigators. What I would love to get to at the at the end of what you have to say about that is, how did the eliminators know what they were doing. And can you say a little bit on that. Well, I think our categorization was pretty well pretty well chosen. I mean, the ones who knew what to do were the ones who had lived through the first SARS and saw that you simply had to get the genie back in the bottle. Because if you didn't, there was going to be trouble. What was, and this is the irony of it all, the eliminators have lost their advantage now under Omicron. If everyone had been an eliminator at the beginning, the genie would have been kept in the bottle or put back in the bottle and cars. COVID-19 would now be over. In other words, SARS is over. SARS is back in the bottle. COVID-19 could have been put back in the bottle had people moved fast enough and had followed the examples of the eliminators. Eliminators essentially Omicron is a result of community transmission and community transmission is what you get if you're not playing the elimination game efficiently. Fantastic. Unfortunately, I think that's about all we have time for in the Q&A. So thank you so much to the panelists for participating. And thank you for a really fascinating renewal of these important findings. And I'll hand it back over to Oscar. Thank you so much, Dr. Jones, on behalf of the Sustainable Development Solutions Network and the Center for Sustainable Development of Columbia University. I would like to thank our co-chair, Dr. Lara Aknil, and distinguished experts for their time and valuable contributions to the work of the Lancet COVID-19 Commission Mental Health Task Force in the last two years. We are also thankful to all the participants who were with us today. Thank you and have a pleasant day.