 Good afternoon. We are now going to start the last session of this first edition of the WPC health conference. As I told you at the beginning, as I said the opening of this conference, the subject of mental health and addictions is usually not brought at the center stage when people talk about health care and global health. We have decided to bring this subject for this first edition because we thought that this somewhat neglected subject is actually of the utmost important globally. The mental health of the population, the global population is a key issue and has to be recognized as such. But also there are a number of global governance issues of interdependence issues. There are some obvious geopolitical ramifications such as the illicit trade, drugs, criminality, and so forth and so on. This is a subject that we usually discuss at the World Policy Conference. But in fact, when we decided to introduce this subject, we had not thought that the mental health situation could be important in the context of the COVID-19 pandemic. And now everybody becomes aware that a population which is forced into lockdown and other restrictions suffers mentally. So this subject is in fact more important, even more important than we thought initially. And I think that this is even more clear after what we heard this morning because at least twice, for instance this morning in each of the first two sessions, the issue of fake news, trust, and so forth and so on was brought into the discussion. And as I think we will see in a minute with Professor Brioni, this issue of fake news, trust is also the core of the mental health and addiction problem. So we are going to start this session with three highly distinguished speakers and we will start with Mikhail van der Berg, who is a health economist and policy economist at the OECD, to give us the broad picture from the viewpoint of an economist. As I tried to say this morning, the economic aspect is really key when talking about health. So we will start with you Mikhail and then we will move to Professor Brioni and we will end with Dr La Blanchie. So the floor is yours Mikhail. Merci beaucoup Monsieur de Montréal. Let me start with a question. What is the real purpose of healthcare? What are health systems supposed to deliver to the people using them? And these questions might be less obvious than you initially think and they have everything to do with the topic that we are talking about today, mental health. And I'm coming from an international organization, the OECD, the Organization for Economic Cooperation and Development and I am there working in the health division and our slogan is just something you see on the wall when you enter the OECD is better policies for better lives. So we do a lot in all areas of health and healthcare. And some time ago I said to a colleague of mine, I know why are we so often talking about mental health as a separate topic, but we never talk about somatic health. And maybe this is because we unconsciously assumed that when talking about health, somatic health is sort of the default. That is to say, is there something wrong physically? It's crystal clear to most people that we are talking about a health problem. With mental health problems, this is sometimes less obvious. So in general, like you mentioned in your introduction, we could say that it's hugely neglected and also highly underestimated. Also in terms of economic figures, we have found that across the OECD, which is definitely not the whole world, but it's 37 member countries, about 50% of the population will encounter some mental health issue somewhere in life. The costs of mental health problems add up to about 3.5 to 4% of GDP across the OECD. So we are talking about a huge and massive problem here. And maybe we are thinking too much in a dichotomy here, mental and somatic elements of health, because these two are strongly interconnected, but this mental aspect may not always receive the attention it deserves in health policy. Now back to our question, what is exactly what health systems should produce? And how do we know that our health systems are actually doing a good job? Now the performance measurement of health systems has a relatively short history, which goes back to the 20th century. And in the 20th century, we would say the outcomes of health systems, life expectancy, curing diseases, because when we live long and breathe diseases, we are healthy, right? And this may have made a lot of sense in the 20th century. And where this was the dominant idea of a healthcare, which was quite episodic, a curative approach. So something is wrong, patient goes to the doctor, Dr. Fields is the problem. But that's not for a more important part of healthcare, it's not no longer the reality we live in today. Populations in most countries have changed dramatically over the past decades. We all have aging populations. And this goes hand in hand with the continuous increase of chronic conditions. And there are morning session, Alexandre, the Gmail has already mentioned that, that this is a massive problem. And in the age group of 65 years and older, for instance, we see that across the OECD, about six out of 10 people live with two or more chronic conditions. So note that the overall prevalence is actually quite higher. We're talking about multi morbidity here. In the overall population, this is about one third. And yes, we need to work on prevention. There's a lot that we can do. But a major part of this population, they're never going to be cured. They're live living with these conditions. And they rely on healthcare to manage their conditions and to provide regular continuous care, prescribed medication, provide lifestyle counseling, et cetera. The purpose of health systems is not so much curing these diseases and lengthing life. It's mainly about quality of life. It's supporting people in what really matters to them. And this is something that cannot be measured simply in clinical outcome measures. You can only get this information by asking patients about the outcomes and experience with care. So when it comes to mental health, we should not just think about disorders or mental diseases. I mean, this is certainly important. But also, we should think about the overall quality of life in general. Now, this may sound a bit abstract, but we are talking about a straightforward thing here. Are people able to do their work? Can they engage in social activities? Or are they hampered in doing this by pain, by concerns, by fatigue, limitations in their mobility, sleeping problems? These are all things that people with conditions are struggling with, and that we can measure. It's really about what matters to people. And health systems should help people realizing their own goals and help living meaningful, good quality lives. And for some of us, this may be a life full of ambition. For others, it has reached a stage in their life where we're talking about being able to be with your grandchildren, to walk your dog, et cetera. Now, at OECD, we are proud to have the biggest database with healthcare-related data in the world. We have massive amounts of data because health systems are collecting these data, prescriptions, admissions, mortality, morbidity, costs, et cetera. But little of these data, I mean, this is all important. It's useful information for health policy. But such data are usually not reflecting the essential questions. Do health systems deliver what people need? Do health systems enable people to live this meaningful life? Such information is still extremely scarce. Know that this is not just my personal mission to get more of this information. As OECD, we talk with our governments, with member states, and in 2017, we had our health ministerial meeting that we do once about every five years. And during this meeting, the health ministers across the OECD agreed that a new generation of health reforms was needed. That we need to make this move towards what we called people-centered health systems, systems that are organized around the needs of patients and ask patients how they feel about the outcomes of their care. And now I know that, I mean, it's difficult to disagree with that. You might say it's maybe easy to reach a political momentum for that because how can you be against it, you know, health systems that serve patients? The issue here is how are we going to walk the talk? How are we going from the narrative to action? And the first logical step is to quote Juliette to actually this morning, data, data, data. We need to start measuring internationally and systematically patients reported indicators. Let's start taking patients seriously and take what they report on their outcomes seriously. And a major misconception here, I think, is that we are talking about soft data. It's not soft data. We talk about really well-validated instrument. There's a lot of scientific rigor and a lot of academic work has been done on how you can measure such outcomes. But it is currently a situation of either these tools are not being used or it's a situation of many flowers blooming. So there are a lot that's being measured, but it's difficult to compare. It's difficult to internationally learn from each other because everybody is doing it slightly differently. Now, let's end with the good news that countries across the OECD have joined forces to start developing, implementing international standards for this under the flag of what you call Paris, the patient reported indicator surveys initiative. And in the past, we have, you may have heard about successful programs, international programs that we had, like for instance PISA in education, where we have developed an international standard to compare the performance of students all over the world. And this has been a real game changer in the world of education. This has also encouraged countries to reform their educational system. And we hope that Paris will be the PISA for healthcare. So we are currently, for instance, working on the international survey of people with chronic conditions who are managing primary care setting. This is the most rapidly growing group of healthcare users across the OECD. And how well these people are served, the care that they receive, it's mainly a black box. And what we are going to do is, you're going to open this black box. And the information coming from Paris will help policymakers to identify best practices and will also facilitate international learning in this area. Now, just to end with a few take home messages. Just like we have been comparing life expectancy costs, morbidity, and so on, internationally, we should also learn from each other by observing to what extent our health systems are successful in meeting needs of patients. There's a lot room to improve and to learn from each other. We can only do this by taking this information seriously. Don't think of it as soft data. It's just essential data. It's about the very essence of healthcare. And just like we develop international standards for all these other measures, we must develop such standard for patients reported measures. Lastly, mental health is something that I think deserves more attention in health policy. We should not only pay attention to it when we are talking about psychiatric labels, but somatic and mental health are closely interconnected. And we should ask people about it and it should be in the center of healthcare in general. Back to you, Mr. Thier. Thank you very much for your presentation. Let me ask you one simple question, because the whole conference is about global governance, that is issues of, well, the political consequences of interdependence. So my question is, in your judgment, what is the global governance dimension of healthcare at the global level? This is actually a topic that is really on top of the international agenda at this moment, as you may know also on the level of European Commission, because if there is one thing that this pandemic has told us that healthcare and health policy is much more an international issue than we may often think. And this is also how I see the role of international organization. We have 37 member states. In all these member states, these countries are struggling with the same issues. They see the same demographic epidemiologic changes and are struggling with the same challenges. And I think I like to think about this in terms of how I call it international learning. There's a lot to learn from each other and to identify best practices internationally, because we definitely know that some health systems across the world are performing much better than others, and that there's a huge opportunity to exchange and to learn lessons from that. Thank you. Well, there is a question I'm going to ask you, but the other two speakers as well. Now, mental health, mental diseases are usually classified as non-communicable diseases, but this is the way they are classified usually. And as an amateur, if I may say so, I wonder if it is true. Is it not true that a mental disease may be communicable diseases, which would of course increase the international dimension? What do you think, Mikael? Yeah, well, we've spoken. It's definitely a non-communicable disease. We can easily agree on that. In the general sense, yes. Yes, but I think I get your point. This division between communicable diseases and non-communicable diseases is a very rough, I mean, it's only two groups. I think there is definitely something more in that, because there is a similarity here with other non-communicable diseases like lifestyle, what we call lifestyle diseases, that there are certain societal developments going on that definitely affect mental health of populations. And while we're living in strange times these days with the COVID-19 pandemic and senior introduction, it's a very good example where we all, I mean, we all in the same boat, we are in this pandemic together, and you see that the impact also on the mental health of populations is huge. It's a big issue. Thank you very much. So now let me move to Professor Roberto Burioni, who is a professor at the University of Milano at the San Rafael University. You are not a psychiatrist, but nevertheless, you are very much interested in these issues. We are talking about this afternoon. And I think if you have, I think you have attended all the sessions this morning, and I am sure that you have recognized some of your favorite topics in the discussion this morning. So in a way, what you are going to say is also a way to wrap up some of the issues that have been raised all the day long. The floor is yours. First of all, I would like to thank Thierry de Montréal for inviting me to such an exciting meeting and to have the chance to share my idea and my point of views with all the experts that are present. We are in an unprecedented moment where really all discipline are converging and are crossing each other to face these pandemics, this emergency, and to face also all the consequences that from this pandemic can come in the in many, many different fields. I am a medical doctor and a virologist, so I should be formally involved in mental health and addictions, but I had the chance in the last years to fight in Italy misinformation about vaccination. This gave me a good hint and a good experience on how to deal with fake news also in the moment that these pandemics started last January. First of all, I'm afraid that we are facing two kinds of pandemics. One is a virus, which is spreading very easily and very fast. The other one, the other pandemic is a make of false information. I think that this can be very dangerous. Why? Because first of all, false information can be very attractive. People want to know that everything is fine, that everything is going well, that everything is not dangerous, and we know this since a very old time, since the work of Julius Caesar, who wrote that people are very likely to believe what they want and what people want is basically say that masks are not necessary, that the virus is not dangerous, it doesn't even exist. And unfortunately, this kind of false informations are providing then the ground for very dangerous behavior of the single person. And we have to remember that to face a pandemic is something that we have to do as a single person. And one, everybody is really equal in front of the virus and everybody can be important for the spread or for the containment of the virus. The second thing, which was very bad, is at a certain point, was diffused also by very important politicians. The idea that some drugs were effective without any proof indicating that. And this was once again dangerous. People were on one hand trying to buy these drugs, subtracting them from people who are needing them for real, and also generating sort of a frenzy, like having the idea, which was pushed, at least in our country, also by some politicians, pushing the idea that an effective treatment is withdrawn from the population for some reason, for some, you know, plot, international plot of something extremely powerful. And then I think that most dangerous issues can be that, you know, fake news can really orient the public opinions in a very dangerous way. When you're telling your citizens that the virus is a Chinese virus, or that the virus, even that the virus was on purpose, constructed and fabricated, and, you know, synthesized in a Chinese laboratory and then spread voluntarily. You really put in the ground for people hating other people. And this is extremely dangerous. We experienced in the past how bad this can be. And I think that this can really be a huge problem for, you know, scientific collaboration from the international point of view, which is absolutely needed to advance quickly and speed it with the science, which is the only thing that can save us in a situation like this. Another huge problem, which is depending on the spread of these false news, is the erosion of trust. Trust on WHO, which is somebody pictures as political entities, which is not, trust on an institution like, you know, governments, Minister of Health, and also trust in doctors, because, you know, in Italy, we had people saying that, you know, everything was invented, everything was made up, and that doctors were just killing people in the hospitals for, you know, creating this emergence, which is really incredible. And this is very, very dangerous because you have to rely on trust. We have to trust FDA for authorization of a new vaccine, for, you know, authorization of new drugs or E-mine Europe. And I think that, you know, trying to push politically these very reputable institutions, as happened, for example, in the U.S., for sure, with President Trump pushing for a prompt, you know, green light on some treatments or even the vaccine. Well, this is very bad because if people are using trust, then it's very difficult to regain it. Well, these are the problems, but I think it's very important also to point out a few solutions. First of all, we need clear, crystal clear scientific data about safety and efficiency. But this is not enough. My experience on vaccines showed clearly that good data and clear scientific data are not enough. We are not anymore in the times where you really follow what the doctor was used to say without any discussion. Now people are trying to get informed themselves through the net, through the social media. And this information is very often incorrect. I mean, there is one example that really is clear for demonstrating how insufficiency are the very good data, very good scientific data. We have one vaccine which is against the human papillomavirus. And this vaccine is actually protecting from cancer, which is not, let's say, a negligible clinical entity. Well, this vaccine is safe. This vaccine is extremely effective. It's wiping off cancer where it's used widely, like in Australia. And actually, at least in Italy, it's completely free. Well, in my country, almost 40% of the parents are refusing, actively refusing this vaccine for the children. And in Holland, the percentage goes close to 50%. In Germany, it's more than 50%. And in France, it's even higher. People refusing a vaccine, which is protecting from cancer, which is safe and which is effective. Well, it's clear that data are not enough. We have to realize that times are changing, and we have to go out of our universities and we have to speak to people. And to talk to people is very different than talking to patients that are coming to our offices, trusting us, or to our students that are universities because they want to learn, or to colleagues that are basically speaking our own language and they understand the process of scientific debate, of scientific confrontation and so on. We are basically talking to people that are not interested in what we talk and they are not very confident in what we say. So we need to be extremely convincing. Another problem is deriving from the fact that many doctors, scientists are talking to public audience with opposing views, which is absolutely normal because in the initial phase of a pandemic caused by a new virus that we never saw before January 2020, it's normal that the knowledge, the precise knowledge is not immense and there is room for scientific opinion. But this is very bad for the general public because if this discussion, if this scientific discussion happens not in scientific conferences, you know, inside the universities or in scientific journals, if this scientific discussion, which is absolutely legitimate, happens in TV show in front of the public audience, this is going to generate a lot of confusion. And here we end to the last point that I want to take to your attention. There is the need of a strong institutional voice. The reason why all these single voices often contract victory are heard is because there is a space, there is an empty space which is left by the institutions. I think that in this moment we realize how important is to have an institution which is trusted, which is convincing, not only providing scientific data, which are correct, but also they need to have the skill to present them in a way that will convince people hearing them. I mean, in this case, the form becomes really the substance. So it's very important the way you talk to people, not only what you tell to people, which is obviously to be true and the correct scientific information. So I think that what we can learn from this very bad experience and what will be useful also in the next month when we hopefully will have a vaccine that could hand could end all this, you know, terrible story of the pandemic that, you know, really impacted very badly on everybody's life and on the economy and all the aspects that we can imagine. Well, we need to be able to give people something to believe in, not only good data, not only, you know, optimistic, you know, let's say provisions, but really we need to convince them that they can trust authorities. They can trust FDA when it will approve the vaccine. They have to trust the government when the government is telling them stay home. The government has to be trusted also when it says you can go to school. And so I think that what we can learn from this terrible experience is that we have to build this trust in, let's say, peacetime, because it's something that will be very useful during the war. And for sure, from the virological point of view, I'm sure that in the future, I don't know when, but in the future we will need to face some other pandemics. I hope we will be ready with diagnostic tools, we will be ready with vaccines, we will be ready to with, you know, isolation and, you know, quarantine and personal equipment for protection, but we'll need to be ready also from the cultural point of view. And we'll need to be able, we'll need to be able to face with the, you know, worried people, with the scared people, with the very authority and trusted voice from the institutions. Thank you very much for the chance I had to speak to this conference and I look forward to hear the other, the other panelists. Thank you. Thank you very much Roberto. We are at the intersection of a number of problems, you know, somatic and mental, but also political and global governance in the following sense, which is that you show that fake news, trust, but that you would also add manipulations of all kinds, make credible global governance extraordinarily difficult. And one of the issues I think related to this is the following one, you know, global, I take a more global approach here. Now global governance has to do with coordination of policies among a number of states, of states. But, you know, states in the international system today are heterogeneous. You have democracies, you have autocratic systems, you have authoritarian system, dictatorship sometimes. And to the problems you mentioned, you can add the classical issue of manipulation from governments, this time from governments, you know, for instance, during the so far, since the beginning of this COVID-19 pandemic, China has been accused, particularly by former president, President Trump, because he's still president of the United States, of having manipulated data, the facts of maybe being that the origin of the whole crisis directly or indirectly. And it is clear that some states use these kind of issues to manipulate the global scene. So here we have manipulation at various levels. You have manipulation, the kind of manipulation that comes in a natural way in social networks and others, and of course, undermine credibility entirely. But you also have classical disinformation and manipulation from governments. And therefore, that raises the whole issue, the whole question, which is particularly sensitive in a time of pandemic, as we are living today, of credibility of global governance altogether. You know, how, what it is, what would be required, what would be the prerequisites for global governance, that not the global public opinion that does not exist, but public opinions with an S could accept, because they would trust those who are in charge of policy decisions. So that's a huge issue, which is related to this last session, as you clearly showed us in your interventions. We propose that we come back to this when concluding in the final debate that will follow the presentations. And now I will give the floor to Jean-Pierre Lablanchie, who is a very well-known psychiatrist in Paris, and who has another virtue, which is that he has educated me a little bit on these complex, on these complex matters. And thanks to him, my mental health is not as bad as it could have been, if I had not met him. Well, so Jean-Pierre, the floor is yours. Thank you. Thank you, Jerry. First of all, this question, are we facing a global international problem? My answer is yes, because this is called human condition. At first, I would like to thank Alessandra Perieu, because she said what she thinks about medical education and this very poor field called psychology. I fully agree with that. And I agree with Jean-Claude Marce, when he said behavior is a key point. Trust is very important. I follow Roberto for the same reasons, and I would add that we are facing people in a regression because of the fear they are living with. And these people are weaker than usual. And in this kind of regression, you can be like brainwashed by some dogma or whatever it is. And we know that for years now. Thanks to his excellency Théros, because he said something so important. We have to invest. And thanks to Michael too, especially when he said that mental health is a somatic disease too. And I will try to point that into speech, because to speak about psychiatry in 10 minutes is quite a challenge. So the question is to protect some at-risk people. And this morning, we understood all that Elderly and co-morbidities affections are very important. And the main risk should be to old people. On this point, I would disagree. Because what we see as a consequence of this COVID-19 huge wave is this mental health problem. Remember, suicide is the second cause of death in young people. 16% of deaths between 15 and 24 is caused by suicide. 20% of deaths in the 25 to 34 in age. So depression kills. It's not of neither virus. So I will argue about three major tests. One is very famous and expensive. And two of them are more recent. And I would like to make you understand that we could invest in that field. These tests are producing data. So what is the link between this COVID-19 wave, depression and addiction? 39% of people have experienced a relapse of their addictive behavior since lockdown. On the national scale, this may mean that more than 1 million people have experienced some form of relapse during the lockdown. It's a complex interplay with financial difficulties, social isolation, uncertainty about the future, and the redistribution of the health workforce, and the disruption to clinical services. This leads to an increased alcohol intake and relapse under lockdown. I have to explain this link with addictions. Addictions to psychoactive substances is expressed in the dependence syndrome. No single logical factor for why some people use drugs and others do not. Why part of them becomes dependent, we don't really entirely know. This must be a combination of psychological, biochemical, genetic, and environment factors which play a role. Studies describe this function in the central nervous system of substance dependence that may also negatively influence the functions of their ability to process sensory information adaptively. There are four problematic personalities, hopelessness, anxiety, impulsivity, and sensation-seeking. We call that sensory processing disorder, or SPD, which is frequently related to these personality traits. SPD is characterized by over or under responsiveness to environmental stimuli. People found in these patterns of over responsiveness to due to their low neurological are frequently described as irritable, moody, express, poor socialization. SPD is frequent co-morbidity of attention deficit hyperactivity disorder, ADHD, and emotional disturbance. This explains why SPD is among substance dependence. This includes decreased dopamine uptake, altered dopamine synthesis, and deficits in serotonin rotech sites. Some people seek for addictive substance as a compensatory mechanism for their unmodulated arousal level or for relief of a particular affective state. Individuals with sensory hypersensitivity showed hyperarousal mechanism, enhanced sympathetic nervous system reactivity, and elevated activity of brain areas associated with hyperemotionality. This is very important. We will see that on the brain skies. This hyperemotionality provided an explanation for the anxiety, depression, irritability, and so forth, and they are seeking for drugs. I will introduce a friend of mine, Rachel Youda. She is the psychiatrist for Ferryman in New York, so remember 9-11. She made some very interesting research showing that this kind of specific depression is a somatic disease. She proved first that huge stress producing the PTSD post-somatic stress disorder affects the cortisol receptors, so you cannot behave like before. She said from someone who was under a ketaspismic event, they are saying they are not the same as they were before. The explanation for that is that this shock can destroy the gene, some genes, activities. This is called epigenetic. If you go to the internet and you type epigenetic and psychiatric, you will see thousands of publications in this field. So first, we have genes. We come back to that. And second, these genes can be hampered by huge, huge stress. What she said, too, is that these kinds of aggressions can be transmitted to the next generation and maybe the next two or three generations. It happens. These patients are comorbid with substance abuse, self-destructive behavior, and medical illness. As a somatic disease, there is a test we can do. First is to check cortisol in the urine. Second is to make a blood test because dexamethasone serves suppression tests. It means that a very low amount of dexamethasone kills your production of cortisol. This means you are under PTSD. This is a very technical but very precise somatic point. What is PTSD? First, it lasts more than one month. And people would re-experience the symptoms of the bad feelings. You have nightmares, flashbacks, repetitive and distressing images or sensations, physical sensations such as pain, swelling, feeling sick, trembling. Some people have constant negative thoughts about their experience. They try to avoid this emotional learning. They try to avoid being reminded of the traumatic event. Usually they go and turn to be isolated and withdrawn. The main treatment for psychological post-traumatic stress is a psychological therapist. I just mentioned cognitive behavior therapy or CBT. I mentioned eye movement, desensitization and reprocessing or ERDR, which is a very good technique we use in case of being stressed. We use that for years and it works very well. You can use medications. First are beta blockers. You use beta blockers to make the debriefing because people otherwise would re-express the trauma and the pain. This trauma is a somatic pain. It's very painful. So you use beta blockers to help people do the debriefing, which is a technique to take care of post-traumatic stress disorders. You can use antidepressants. Park-setting sertraline are agreed for treatment for PTSD, but you can use some other treatments. Something very specific to this coronavirus way, this is what said Professor Mario Le Boyer. Some U.S. publications did exactly the same observations. It seems that there is a protective effect against directly the coronavirus of certain drugs widely used in psychiatry, especially antidepressants on zoolytics and even antistaminics. This was done in Henri Mondeur hospital. What was the consumption of psychotropic drugs during the COVID period? It increased. For the first wave, we've seen an increase of 18.6% of angiolytic use. So same for antidepressants. Now, I will try to explain what we can do on a large scale. As I said, psychiatry is not very well known in the medical field, and psychology is less. So this test called the Minnesota Multi-Fasic Personality Inventory is the interest psychological test. It began in the 40s. It's the most published psychological test. It's very accurate, and we can use it especially to deal with psychological stability. For instance, for workers at high risk, but there everyone was at high risk. This test is very easy to do. You have 330 questions dealing with hypochondria, depression, hysteria, psychopathic, deviate, masculinity, and femininity, which with paranoia, psigastemia, schizophrenia, hypomania, and so forth. It shows a like a sheen where you can see easily that when you are all in the blue situation, everything is okay. So you just point out the points which are out of this sheen. You have many of them, and it's very accurate. So after this explaining very briefly what is this psychological test, the second point is to go to brain spec imaging. This is more expensive, but this is very accurate, and I want you to see some pictures. For you to understand, this is a somatic disease. It's not a state of mind. It's not an impression. It's not an emotion. So we have nowadays kind of tools mixing at the same time a PET scan and an MRI. And when you do the integration of the pictures, you can see the metabolism, mostly the metabolism of the neurological cells. So you can see functionally how the brain works. So here on the left, you have a normal scan. On the right, you have a scan for people taking drugs. This is an edited brain scan. At the top, you see how this kind of scan for marijuana users. Then you have the effect of long-term use of heroin. As you can see, the pictures are not the same. Then you can see what's doing metamphetamine and then alcohol use. So as you can see, we can now figure out what is the result of the use of drugs in terms of functional and it's a somatic disease then. It's not an impression. So alcohol with drugs at the top and then effect of heavy nicotine and caffeine abuse. The third point is that now we can use genetic as a preventive test for emotional instability. These tests are now used for something like 10 years and what you can see is how you were born with some genes which were not functional. Who do you test? Good disorders, anxiety and impulsiveness, sleep disorders, fatigue, suspicion of depression, impaired concentration and impaired activity. Just remember you that it deals mostly with two main hormones called serotonin and dopamine. Serotonin is like a break and dopamine is like an accelerator. So these are examples of mutations. We should have we should have nine lines in black which means nine functional genes. The first one you have three genes mutated. The second one you have four of them. The third one you have eight of them and the last one nine and nine. Frankly I did not know this would exist. This was the first time I met this kind of results. This makes catastrophic life. This is important for many reasons to do this kind of test because it helps the psychiatrists to explain the patient should take a treatment because this last person with nine on nine mutated genes refused absolutely to take any kind of drug and I had to explain with this kind of situation I cannot do anything with just using psychotherapy. This guy accepted at the end to take this treatment and then is very very in a better condition. Other interesting points that when you can explain that to patients it means they were born like that. They have to deal with it all their life long and try to live much much better. And this is not the parents fault. This is not the education. This is not the environment. This is for them. This is a genetic problem. I have to say again that these are genes at the origin but some of normal genes could be hampered by shocks and with epigenetic modifications. So to conclude there is a third way which would be a mental health way of saying how a minister of health Mr. Will what I would like to for confusion to say that in facing this difficult human condition this huge suffering with a very high risk of disease killing people first we have tools. First of all we have to explain to people that dark thoughts never never are normal. If you feel this kind of thought you have to call someone for instance a clinician a psychologist a psychiatrist. Second we can use very easily this kind of test and describe and just describe why there are plenty of them but this one is very useful and very well known test. It takes one an hour by phone at a distance or whatever to make the diagnosis much more precise than the impression of the psychiatrist of a clinician. Second you can use genetic tests for educational reasons and third medical imaging is just incredible. We made extraordinary progress and this gives data for some kind of somatic disease I insist. Thank you. Thank you very much Jean-Pierre for this brief course on the Psychiatrics. It's extremely interesting now what I suggest during the 25 minutes which are left for general discussion is to concentrate to really concentrate on international aspects of all this. For instance Jean-Pierre if you take the PTSD the post-traumatic stress disorders if I am not mistaken historically the interest in such subjects started after wars and of course the Crimea war in the 19th century but particularly the first world war was quite important in this respect historically but there are not only war disorders I mean the PTSD caused by war but also for instance the Great Depression I don't know if the Great Depression of the of the 30s of the 1930s I don't know if there were studies on the mental disorders as a result of a Great Depression such as that of the 1930s and now of course we have the COVID-19 and it is very likely that future epidemics or pandemic will have such consequences. So my first question to you Jean-Pierre but also to the panel my first question is are there already some basic principles that should guide those who are in charge of of global governance in this area who are starting the WHO but not only the WHO you know other organizations because again you know this topic is not often covered in discussions on global health so my first question is can we draw some at least interesting principles on this issue and the second point I would like to make also as a question when I joked at the beginning of this session speaking of mental disorders or as communicable diseases of course it was not in the medical sense it was in the sociological sense and I remind all of us of the very famous book by the French sociologist Émile Durkheim which was published I think at the end of the 19th century which showed that the surprise of many readers that suicide was also a sociological phenomenon so if suicide is also a sociological phenomenon not only a health a personal situation maybe there are other kind of disorders for instance alcohol it's very one doesn't need to be a great psychiatrist to understand that young people drink alcohol because they are together because and when you are together usually you that's the exacerbates certain kinds of behavior so my question my second question to the panel is if it is true that many mental disorders many mental diseases or the the the the the psychic side of of health if it is true that the the collective aspect is important the societal aspect is important what what kind of consequences should be a draw from that in trying to shape policy advice at the global level so these are my two questions again we don't have there are many many others but perhaps we could take these two so maybe I will give the floor to professor Buriani who would like to comment on this and I will give the floor to the two other speakers before we conclude well I go ahead and I will reload surely I think that this kind of you know massive change of of life because we were stuck in our homes for for a long time I'm sure that and a strong effect a heavy effect on the psychological equilibrium of the people and also unfortunately and in fact also on the lack of screening of a lot of visits for controlling like say any kind of medical conditions so I think that with such an emergency we will need to face now and in the future a really complex modification I'm not talking about mental health because it's not my field but I can assure you that the disruption of the common let's say medical practice has been very very heavy because many hospitals are literally closed down anything which was not emergency or COVID-19 included so it doesn't surprise me that also from the mental health point of view the toll thank you very much so thank you very much Roberto so Michael yes Jay I I'm glad that that in the company I'm in the company of two doctors here so I'm glad you mentioned Durkheim because I'm a sociologist and I think what we could learn from that is as you said it goes for suicide but also for other mental health conditions what Durkheim showed that it's strongly connected with social cohesion so a feeling of being connected with other people and being integrated in social groups and I think now it is certainly applies to also the time that we're living now in the pandemic what we see throughout the world is that we have these crisis teams and task forces of very well-equipped people but they're all composed of people who are working on virus contaminants you know it's a very biological focus I think managing the what what is often often called the sort of collateral damage of this is I think something that should have a high priority in how we deal with this kind of crisis also psychological effects the effects of confinement and and don't get me wrong confinements are necessary I absolutely support that but it's true that for some people the effects are are quite disastrous of being not connected to other people and I think that from a mental health perspective is definitely a risk thank you very much Jean Pierre yes this morning you said something like we are at war or not indeed our president declared that we were at war so the history of the post-traumatic stress disorder begins in the first during the first word war sure had this chance to work and to be the colleague called the general and professor we croak and he trained me in term of the narco analysis and this treatment was a weapon this played a huge role during the battle of England because you had so many planes but so few pilots so as as quick as possible one one pilot was taken back from the sea where I did land we would inject him and he would go back to his plane in the next hour so it's a it's a treatment it's a physiological it's a somatic treatment which treats this kind of psycho somatic disease it's a disease second we had much more information than with the other wars including the u.s in iraq for instance where we discovered that people treated with ketamine for anesthesia didn't develop post-traumatic stress disorders it's why now we have the first new treatment for 50 years called esketamine which is an injection by those to treat resistant depressions so observing these war situations treating these people in emergencies as as lead to new treatments so so I insist there is a real medical condition it's not an impression or whatever but I would add to that I insisted on hypersensitability hypersensitability is one face on the of the coin the other one is toxic abuse it's dependency so your addictions is linked to hypersensitability if you make the diagnosis if you help people deal with this hypersensitability you help them cut with addictions to very specific question what what is the definition of a trauma because because it's well all of us are traumatized every day but by many things so this is very low level traumas but when when is a shock so high that it becomes a real trauma for instance in that if I if you take if you compare a real war and the current situation of a pandemic one feels that it is not the same magnitude so so how how do you define medically the the the level where the the real trauma exists I did it my dear cherry it's dealing with your own sensibility the same event has not the same impact I was with professor we croak and the and the san michel station during the bombing some people were there they were not shocked at all some people now are still under treatment so it's not the event by itself it's the way you receive it the way you interpret it and the way you will deal with it some people had a huge post-war trauma by just losing their cat and it's serious for them it's not the it's not only the what you can think of the explosions or crush a plane and so forth it's it's the way you receive it and your sensitivity it's why I insisted on hypersensitivity well thank you very much and of course there are statistics which show the percentage of the population of the distribution over a population and and and that's also a epidemiologist study there are epidemiology studies on this sensitivity that that exists I suppose yes but this is a practitioner knows because when I said we still have something like three percent of the people in the san michel station under treatment now three percent it's it's a very low but it's still there so now I would like all of you to try and answer my question so I repeat it the question is what kind of recommendation or if not recommendation at this stage what what do you think should be deepened in order to shape or to start shaping some global policy some some global policy elements that do not exist today on this issue of mental health and addictions so a brief if you could each of you try to give brief answer again I use the word recommendations but I don't it's it's it's premature but at least some some ideas which we could try to deepen within or outside the framework of the world policy conference so I would answer by one point just one point did you know about these kind of psychological tests did you know about genetic tests did you know about this new MRI most of you didn't so my answer is education education training for mds for psychologists and and and share this kind of knowledge much more thank you very much roberto well I think that what's very important from the larger let's say the definition of mental health is do not to undermine the supranational institution that we already have and they're doing a very good work which is basically WHO it's really irresponsible to undermine the authority is very very very something very bad and it should come from governments as it happened on the other hand that will show as a great responsibility it doesn't have to appear in any way something which is related to politics that will show as to be only science so that this is something we already have and we have learned that the stressful situation fake news that blaming other people can really undermine the geopolitical equilibrium really something which we don't want because collaboration is the basis of the advanced we don't have to forget that the vaccine was made by two American companies in an unprecedented short time but the sequence of the virus was provided the general return but by Chinese scientists this happened because the Chinese scientists to relieve the the sequence American scientists and German scientists worked on it so I think that at the very end of the story we have shown in practical terms how much collaboration between countries can be very good for everybody and so we I really personally hope that WHO will keep on retaining the moral and scientific authority that it has without you know politician going to undermine them well thank you Roberto I think this is also related to the education aspect of course that is to to to to let better know what real authorities have to say if I understood the properly but if actually the problem it seems to me one of the problem is that the great the vast majority of the population or populations are even if they are educated in a very basic sense they don't know much about complex issues you know the that's very clear you know most people ordinary people average people do not know much about economics unless they were trading economics they don't know much about about medicine unless they were trained as medical doctors and so forth and so on and nevertheless in democracy everybody has a right to express himself in every field including those where he has no particular education and this means that it can work only if trust is there so we are always back to the same to the same question because it's impossible for anyone to be a perfect citizen that is a citizen that would be able to make well-thought judgments on every kind of issue so if you are not able to do so yourself in any individual cannot do that it means that you have to trust some sort of authorities over the the in all the fields and dimensions where you yourself are not particularly competent so we are always back to the same problem is it not true yes i think i completely uh michael yes my well some of the things that i would like to highlight is i think three things one of the things that we didn't talk so much about it in this session but it has been one of the common threats i think today what i mentioned data data and mr moria for instance mentioned this about the interoperability internationally when it comes to health data we don't have such a thing as an international data system like we have in banking for instance and we all know that if you want to improve something you need to measure it and it may not be feasible to have an international health data system in a short term but what we can definitely do and that's what we we spend a lot of time on that and always bringing together stakeholders and countries and develop algorithms together to be able to learn from each other to compare and like we do in pizza but also in other data collections that's really a way to facilitate international learning i think also in this domain specifically for the air of mental health we have developed also an mental health international mental health framework um well there's no time to dive into that but one thing that really stands out if you talk about it all over the world is that there is a problem with access and there's a problem with awareness of this problem of mental health because we have this striking figure of what we said 50 of the population has to deal with some mental health issue once in your life but another striking figure is that we know that across the OECD that about 80 percent of people who have mental health problems remain treated so they never find the way to a healthcare and that is a huge problem that has to do with stigma on it which might be much more in some cultures than others and it has to it is related to access and this is a major issue i think that that we need to work on and am i last command is well it is is connected to the story that i already told i think the way we think about mental health and we think about how we design health systems is that we should think about mental health not just in terms of disease or disorders but also in terms of quality of life because it's not just let's move away a bit from just this disease focus to which a more people centered focus well thank you very much we are now approaching the end i think it was good Michael to come back to this question which was raised several times this morning about data but i think that data data data is is not enough because an algorithm is not enough too because the problem is the mindset of the people who interpret data and the mindset of people of people who who build algorithm for instance if you are an economist trying to interpret the the world today in a very global way if you are a marxist there are still people who think like in marxist terms if you're a marxist or if you are liberal you will come to two totally different interpretations of the same data so it's not enough you know to have for instance a common data base it's important also to agree if you want to act at the global level to agree on some on some interpretation on some model to interpret the data and here it's not obvious i mentioned in my opening comments this morning i mentioned i draw a comparison with with arms control in the soviet time you know that when at the at the beginning state at the early stage of arms control when the american experts and the soviet experts met for for the first for the first time they had no common language and and and it took a month if not years you know for the negotiators for the negotiators to come to agree on a common language you know the missiles for instance had different denominations in in both countries and there were much more complicated issues so it seems to me that when one faces complex problems the the first step of course is to agree on the on the language and and some principles of interpretations in in other words the data without models is almost useless so you need and if you are a good pilot and you don't have a plane you you cannot fly and if you have a wonderful plane but you you you cannot you are not a pilot there is no pilot you cannot fly also so it's there are complementary problems you know of complementarity and my last word for this fascinating day is that if we bring the subject of global health in the wupc it is precisely because the usual customers you can say so participants members of the wupc are people who are who have an interest in in global governance issues in general in general from the global viewpoint there is a wonderful very rich community of experts on global health on health care problems but most of them have a very limited understanding of familiarity with political issues and international politics in general so what we are aiming at with the wupc health in the wupc in general is to try to bring the two together so that some useful insights could be developed thanks to this complementarity and transdisciplinarity if i we should always the case with complex with complexity so i propose to conclude with these words and we will be in touch with all the speakers of today's conference who will be in touch very soon the whole debates of this day will be on light on the website of the wupc tomorrow that should be put on this on the website tomorrow and as you know there will be a book printed as soon as possible so in the next few weeks with your contributions or written contribution and some summary of the of the debates that that book will be widely distributed before the next plenary of the world policy conference which is scheduled at the end of the of February so thank you very much all the speakers all the contributors my personal feeling is that for this first edition of the wupc health was a success thanks to you and there is a lot of food for thought and many issues i think which have been identified and that we will try to to deepen in the next meeting so thank you everybody and i look forward to seeing you soon