The Netherlands started screening for Breast Cancer 30 years ago. During this period, we learned a lot about the benefits and harms of Breast Cancer screening and therefore we constantly adjust the Dutch programme in order to optimise it as much as possible. This optimisation resulted in a mortality reduction of 50 per cent for women who do attend all screening rounds between the age of 50 and 75 in a biannual setting.

Due to our experiences, we developed a philosophy regarding the organisation and maintenance of a screening programme, based upon six pillars.  

At first, we think of screening like a medical chain in which equipment, technicians and radiologists are the key players. This chain is as weak as the weakest link. Therefore, before starting a screening programme all three links have to be secured. In practice this means that an adequate educational programme as well as a system for quality control has to be implemented before starting the actual screening process itself. It is a misperception that starting a screening programme is equivalent to buying equipment.

The second important issue is to discriminate between clinical breast radiology and screening for breast cancer. The mindset in a screening environment differs from a clinical setting. In screening you only have to depict lesions with a high probability for breast cancer. All other lesions are not of interest in a screening setting. This requires additional training not only in a theoretical setting but even more it requires specific skills.

Therefore, in our opinion a radiologist is not a screening radiologist unless these specific skills have been trained. In the Netherlands, it is obligatory to pass an additional training before you are allowed to work in the Dutch national screening programme. The additional training is also obligatory for technicians. Apart from the certification of professionals all equipment has be certified as well. This is the third pillar of our system. Certifying new mammography equipment before installation, weekly calibration of every mammography unit and extensive testing every six months is part of our quality control system.

In order to maintain the highest quality possible and adjusting the individual performance of Technicians and Radiologist, auditing is essential and accounts for another important pillar of our philosophy. During these audits, which take place once every three years, we benchmark the results from screening units all over the country. This gives insight in the regional performance in comparison to the national performance. During these audits, we arrange peer to peer discussions between the auditing team and the screening unit, which is audited.

In this way we have created a system in which scientific discussion forms the basis of adjusting the programme instead of signing out of a list of items. The combination of benchmark and peer to peer discussions makes fine tuning a real option in the Dutch screening programme.

Another important element of our quality system is the recall rate. When we started screening 30 years ago, we thought that a recall rate of 1 per cent would be optimal for the Dutch programme. The advantages of this low recall rate were a high positive predictive value (this means that relatively few women were recalled for a benign lesion) while detecting a lot of breast cancers at an early stage. After evaluating this recall rate by means of ‘the optimisation study’, published in JCNI 2005, we changed our policy and went up to a recall rate of 2.4 per cent. Still very low compared to other countries, especially the U.S., but with the same breast cancer detection as in other countries (6,8 per 1,000). We pay a lot of attention to recall rate in the Netherlands. Recall rate reflects in essence the balance between benefits and harms of a screening programme. The more you recall, the more falls-positives (woman recalled from the screening programme but no malignancy after assessment) you will have.

False-positive recalls should be avoided as much as possible because it constitutes a serious drawback of screening without compensatory benefit for the affected subgroup of participants. In studies performed in the Netherlands, we discovered a drop in re-attendance after a positive recall as high as up to 30 per cent. Anxiety and discomfort for women as well as high costs for the community (additional imaging and image-guided interventions) makes false-positives a serious item to evaluate, educate and control. Defining a recall rate, teaching and training skills of radiologist forms the backbone to minimize harms in a screening programme.

The last pillar is about data. Data are essential in a screening programme. Not only information regarding incidence in relation to age, but also recall rate, detection of breast cancer, interval cancers (symptomatic cancers that appear between screening rou nds), stage of detection and in the long run figures in survival are essential to evaluate and adjust the program. In the Netherlands, we have central storage of all mammography images produced during screening. But we also have a unique custom-made reporting system. Besides that, all pathology reports from all over the country (not only breast) are stored centrally as well as all data regarding cancer (all cancer types). Coupling of these databases makes it possible to evaluate the Dutch screening programme on a national level. This gives us the opportunity to calculate other items like overdiagnosis.

Our philosophy that screening differs from clinical breast radiology also accounts for the women involved. Therefore, screening in the Netherlands is arranged completely outside the hospital setting. We have 58 trucks with mammography equipment driving throughout the country to facilitate women to have their mammography once every two years (paid for by the government) close to their home address avoiding a clinical setting. Apart from the 58 trucks, we have 20 stationary systems outside hospitals. This concept is accepted very well and is reflected in a constant high attendance rate of around 80 per cent. Only in case of recall and further assessment women are confronted with a hospital setting.

In conclusion, screening for Breast Cancer works but it requires a solid infrastructure consisting of education, monitoring auditing and continuous adjustment. The Dutch model reflects a comprehensive system resulting in a serious reduction of breast cancer mortality. The Dutch Expert Centre for Screening (LRCB) is frequently consulted by countries that want to start or set up a screening programme. Adjustment for local and cultural background is essential for making the programme successful. But regardless, the country or cultural background, education is the key to success.

Rurik von Hagens, Managing Director, von Hagens Plastination tells Daily Dose: “von Hagens is involved in plastination, a process, which my father invented 40 years ago in Germany. What this process does is that it permanently preserves human bodies. The preservation is first of all permanent and will last longer than the mummies of the Pharaoh!

"It can show a level of detail, on these permanently preserved specimens, which are not possible anywhere else. It is, therefore, perfect for medical teaching – they are dry, non-infectious, so you don’t have to worry about any health hazards, and at the same time it is the best tool of teaching you could have.”

Rurik shares that von Hagens started as a small venture but after 15 years, they started the world-renowned exhibition Body Worlds. The primary goal of the exhibition is preventive healthcare and it was conceived to educate the public about the inner workings of the human body and to show the effects of healthy and unhealthy lifestyles. It is aimed to inspire visitors to become aware of the fragility of their bodies and to recognise the anatomical individual beauty inside each of us. Currently, there are 11 Body Worlds exhibitions in the entire world.

Furthermore, Rurik emphasised that for von Hagens the ethical side of the business is of utmost importance because all of the specimens are real people. “It is really essential that we have donated bodies for these specimens. We have our own donation programme and the people who are shown here today decided during their lifetime that they would either be part of an exhibition or that their specimens would be used in medical teachings. This is something that is very important for us.”

“Body Worlds is one of the most successful exhibitions in the world that attracts a large number of visitors,” says Rurik. “The exhibition has a strong impact on people because everyone has a body and the exhibition is all about you. It allows you the possibility to see under your skin. You learn about living from the dead at this exhibition.”

Each exhibition contains real human specimens, including a series of fascinating whole-body plastinates as well as individual organs, organ configurations, blood vessels, and transparent body slices. The plastinates take the visitor on an exciting journey under the skin. It provides wide-ranging insight into the anatomy and physiology of the human body. In addition to organ functions, common diseases are described in an easily understood manner by comparing healthy and affected organs.

It demonstrates the long-term impact of diseases and addictions, such as tobacco or alcohol consumption, and shows the mechanics of artificial knee or hip joints. Individual specimens are used to compare healthy and diseased organs, i.e., a healthy lung with that of a smoker, to emphasise the importance of a healthy lifestyle. He highlights that the company would love to bring Body Worlds to Dubai, because the exhibition is not just for schools but for everybody. “Everybody has a body, and everybody should be able to see what they are made of. We still have to find the right venue and partners, but it is something we are looking into and we hope that happens in the near future.

“At Arab Health, our aim is for people to learn about our specimens and how special they are. Many people have somehow heard about the process, but it is something very different when they see our specimens in reality. They see the very fine dissections that we do, so even experts say that “I heard about it, I read about it, but now that I see it, it is something so different”. Our main target is for people to see it so that people are aware of how special they are, and this is only possible when they see it in person.”

Teaching Tool

Rurik highlights that the company provides these specimens for medical schools as it makes for the perfect teaching tool. “So, any medical school with a good teaching programme in our opinion should have one of our plastinates. New York University in the U.S. uses them, so does Warwick University in the UK, among other leading educational institutes all over the world. More and more institutions are starting to use it. We started offering this just five to six years back and are still a little bit at the starting point here even though the technique is very old. But already many well-renowned universities are using it, right from Singapore, to America, to Europe, and to the Middle East,” he adds.

Rurik shares that the company is attending the show for the first time and his impression is that a lot of attention is paid into healthcare in the region. He says: “A lot of investments are made into healthcare here, there are many new schools here and overall, they really pride themselves on excellency here. And this philosophy fits very well with us because these are the very same values that we represent.” He highlights that Leader Healthcare and von Hagens also recently did an installation for Khalifa University Abu Dhabi.

He stresses that the company’s big vision is that any university teaching should have plastinates. “For this, we are really working hard and are having more than 75 people working in Germany on making specimens. It is a very time-consuming and hard process, but our goal is really to expand that. Every school should have that. We are also further developing and are developing the exhibitions, adding new themes and specimens to the exhibition, and that’s our way forward,” he concluded.

Sukhdeep Sachdev, Global CEO, Leader Healthcare adds: “Donors of the von Hagens programme have declared that once they die their body can be used for research purposes. When the person dies, they can take a specific organ such as the heart, kidney or pancreas, and through a process of plastination they are preserved for the next 20 years. The advantage with this is that researchers then get to know human specimens exactly. They can observe each neuron, cells, and tissue structure, so the teaching becomes better. It is going to be one of the highlights for us at the show.”

This is where Sukhdeep Sachdev, Global CEO, Leader Healthcare, says that the company is bridging the gap and is providing modern tools and technologies. The company sources the very latest equipment and brings it to the doorsteps of the surgeons and convinces them to try and adopt these in their practice. Furthermore, the company has aligned its forces with the vision of the UAE’s healthcare landscape and has structured its policies according to what the nation needs.

With Leader Healthcare celebrating its 10th anniversary this year, Sachdev, in an interview with Daily Dose, reflects back on his journey in the UAE. He came here in the 90s and shares that he worked at a conglomerate for almost 17 years, which he credits taught him a lot about how to be a skilled entrepreneur, and how to be a leader. Leader Healthcare started as a one-man company in 2009 and today it employs over 200 people and is present in 11 countries.

He says: “In 2009, I thought that it was about time to embark on my own journey and I started Leader Healthcare. When I started the company and was hiring people, I was not looking at their CV but at what are their dreams were and if Leader Healthcare could help build their dreams. That is one side of the story. The other side was that we were looking to have a strong organisation that could fill the gap in the marketplace. Dubai is renowned as a trading hub and we wanted to bring the best innovation and technology here.”Sachdev highlights that there are strong institutions and healthcare providers in the UAE, but he felt that there was a need for a strong organisation that could provide them with innovative and creative technology and teaches them how it could be integrated to meet the basic needs of the patient.

“One of our greatest achievements I would say is that we have positioned ourselves as a strong company in the field of healthcare when it comes to technology. We have also diversified in the last couple of years into various businesses for patient care such as providing medical equipment and technology in homecare, providing rehab equipment, and how to help children with autistic disabilities with technology, so that the parents can feel better when it comes to the welfare of their kids, among others. We have also moved onto education in healthcare and that will be the strongest area we excel in, in the next couple of years,” he emphasises.

Focus on Clinical Education

Clinical education is one of the key areas of attention for Leader Healthcare. Sachdev stresses: “We have realised that when you are talking to a physician or nurses, you need people who can speak their language. Leader Healthcare has expanded its team by hiring those intellectuals and team of clinical educators. These educators meet a team of nurses or physicians and make sure that the technology that we are providing is integrated in the healthcare environment.

“When we talk about integration, we mean that they can actually utilise that technology in an effective way. In the end, everyone has got one aim, which is the patient and that’s what Leader Healthcare is focusing on. Our bottom line is that we talk to healthcare providers and see how well the patient can improve with these particular technologies that we are bringing in. The best way is to teach them and educate them through our clinical educators.”

Furthermore, the company is engaged in a number of projects in the region such as in Saudi Arabia. It is also recently in the process of executing a contract with Bahrain Defence Forces and is helping them build a complete virtual hospital. The five-storey structure is over 70,000 square feet, and the company is trying to integrate a complete skill set there, not only in healthcare but also in their military environment and by training medics in the field. In the UAE, Leader Healthcare is in active discussions with Khalifa University Abu Dhabi and are helping them bring state-of-the-art technologies.

Sachdev highlights: “In fact, in the last three months we have delivered unique innovative technologies. One of them is a company called Anatomage, which provides digital dissection. Your finger is your scalpel, and with just one single finger you can dissect the body digitally. Universities will use maybe 15 to 20 cadavers a year, which cost around US$10,00. So, what we are telling them that they can reduce this cost by opting for a digital table, I can bring the cadaver here, I can dissect, and I can zoom, and talk about any part of the body and we can teach multiple number of students at the same time rather than just three or six students.”

In the next five years, Sachdev says, Leader Healthcare hopes to be in every continent. “We have already started working on that goal. We have expanded our operations to India, have gone into the APAC region, with headquarters in Australia, we are in New Zealand and the next step is Singapore.”

He concludes: “We are very excited about our 10th anniversary. The pledge we have taken here is to go on a global path, especially in the field of education in healthcare. We are working on the genes of our people and are helping them to build their dreams and want them to feel that they are a part of an employee-owned organisation. The growth that we have seen in our 10 years has been phenomenal. We are very proud of our people and our team and will continue the building our success story.”

What’s in store at Arab Health 2019?

Sachdev highlights: “Arab Health is going to be full of surprises and that’s been our aim every year. We don’t want to be monotonous. We want to mesmerise people and keep them guessing about what’s in store. This year our showstopper is going to be a company called von Hagens from Germany. We are going to bring live human specimens that will be used for the students of tomorrow. The company pro-duces actual human specimen through a process called plastination. What happens is that it doesn’t give students something artificial to learn but provides them with the actual human specimen. Apart from that, we will have an immersive room. It is part of the technology people have been talking about such as AR and VR. One of the companies that we represent, CAE healthcare has tied up with Microsoft and we will have a showcase of HoloLens, a technology that is widely being used in the industry not just in healthcare. But with that technology again, the education focus can be really enlarged. You will see some really awe-inspiring innovations at our stand H4.D30.”

He says: “Sometimes it is a new design for a product or a completely new innovation. The UAE is an important market for us, and we have been present in the Middle East and the UAE for over 20 years. The UAE has the goal for Expo 2020, so they have to build an infrastructure with that deadline in mind. We are here to help them meet those needs.”

The company was founded in 1985 by Joel Honigberg with several divisions. One of the divisions that came in later was the medical division. The focus of the company is to represent U.S. manufacturers overseas and it works with a network of established distributors. The company’s role is to look at regulatory aspects for medical devices, and what is required so that they can enter and comply with the regulations of each specific country.

The company’s products can be divided into three different categories. There is radiology, which includes imaging tables, x-ray protection; hospital furnishing equipment, which includes medical carts, exam tables, warming cabinets for fluids, and emergency equipment, which would include ventilators, suction equipment, etc., among other products, such as pill counting machines. The distributors import the products and sell and install it for hospitals and clinics.

One of the innovative products on display is the Operation Heatjac Warming Belts that keeps physicians and nurses warm in the operating room.

Forcier says: “This vest was designed by an anaesthesiologist. It is cold in the operating room, so, he had the idea of having a belt that can have a battery pack so you can walk around or you can plug it into a socket. But to be even more efficient he thought of having an insulating vest and instead of batteries, you can have heat packs that trap the heat along your body for over 12 hours. The product is something very new on the market. Also, it is something that can go way beyond the healthcare facility, as anybody who is cold can use it and it can have multiple applications.”

Another one of the unique products on display is ivNow, which is convenient and easy-to-use, and quickly heats and maintains safe temperatures of intravenous fluids while saving time and space.

“IV fluids are traditionally warmed in cabinets and usually a nurse would have to go outside the operating room (OR) to get the IV bag and when someone goes outside of the OR and back in, there is a risk of contamination. ivNow allows you to have immediate access, while giving prominence to safety,” he adds.

Forcier concludes: “We always look for innovative ideas and aim to bring easier as well as high-quality solutions to the market. We have all the required certifications and our goal is to introduce products that are useful and safe for both the hospital staff as well as patients.”

Long considered as a disease of Western countries of Europe and North America, today, T2D is spread to every corner of the world, with more people with diabetes residing in the “emerging” economies than in the industrialised nations.

In 2017, it was estimated that 425 million people worldwide, or 8.8 per cent of adults have diabetes, with T2D making up more than 90 per cent of all cases. It is estimated that by 2045, if these trends continue, 629 million people aged 20-79 years, will have diabetes.

Diabetes rates vary greatly across different regions in the world. The Middle East and North Africa (MENA) region, which include the Gulf Cooperation Council (GCC) States, was estimated to have the second highest rates of diabetes in the world. At the global level, increased diabetes rates are most evident in countries that have experienced rapid economic growth, transitioning from low-income to high-income economies over a short period of time; the case of many countries in the Gulf Region.

Indeed, over the last three decades, the discovery and exploitation of oil and gas in several GCC States, has led to a rapid increase in economic growth and urbanisation in the region. This has been hypothesised to have resulted in a modern, fast-paced, and a technology-driven lifestyle, which consequently led to the reduction in physical activity levels, excessive consumption of calorie-dense fast meals, and eventually to the rapid rise in obesity rates and its related comorbidities, such as diabetes. Although this could be true, this is still a debatable topic.

Diabetes Risk: More Than Eating More and Moving Less

Unhealthy eating and lack of exercise are two of the well-known and established risk factors of T2D. Whilst that is true, there are various other environmental exposures that have shown to influence risk of developing T2D. These range from air pollution, stress, and disturbed sleep, to vitamin D deficiency and viral infections. Some of our research at the Imperial College London Diabetes Centre (ICLDC)  includes looking into the link between obesity and diabetes with adenovirus-36 infection, which we think will bring along interesting results for the Emirati population, and the Middle East in general.

Despite the accumulating evidence on different lifestyle and environmental factors affecting risk of diabetes, obesity is still thought to be the major contributor to the dramatic increase in T2D over the last 20 years, globally. That is thought to be the case across most populations, including those of the MENA region. The question is, can increased obesity explain the high rates of T2D in the region? The answer to this question is not straightforward. Although obesity is a major risk factor for T2D, yet not all those who are obese develop the disease, and not all of those who are at high risk of diabetes remain disease-free by losing weight. In the case of populations in the Gulf, available estimates of obesity and diabetes indicate that obesity cannot fully explain the dramatic rates of diabetes in the region. It is true that high rates of diabetes in the Gulf are paralleled with high rates of obesity, yet, other countries in different regions in the world, including the U.S. and the UK, have comparable obesity rates to the countries in the Gulf, but much lower rates of diabetes. Similarly, rates of physical inactivity in the Gulf is reflective of the increased diabetes rates. However, countries in other regions in the world, have much lower rates of diabetes despite having comparable rates of physical inactivity to countries in the Gulf.

Data available make us question whether people in the Middle East are more “genetically-prone” to developing diabetes compared to other ethnic populations. It has been shown that certain ethnic populations are at a considerable higher risk of developing diabetes. Whilst in some cases this can be explained by socio-economic factors, and access to healthcare, it has been proven that even with equating all factors, ethnicity still plays a part in increasing or decreasing diabetes risk. If that is the case in the Middle East, then for example, a 30-year old man from Kuwait, Saleh, who is obese and/or inactive, is at a higher risk of developing diabetes, compared to a 30-year old man from the UK, John, who is also obese and has similar activity levels and dietary intake to Saleh. Now, does that mean that Saleh’s destiny and ours solely depend on our genes? That is not exactly true.

Increased Susceptibility to Diabetes: Your Genes Are Not Your Destiny

It is true that certain genes can predispose us to T2D, but predisposition is not pre-destiny. In fact, if the genetic architecture of the people in the Gulf make them more prone or “sensitive” to developing T2D, then it could also make them more responsive to lifestyle changes. A person’s susceptibility to developing T2D is speculated to be more complex than just obesity, or physical inactivity, or diet, or genetic risk factors alone; it appears to be driven by a complex interplay of gene-environmental interactions, called Epigenetics.

Epigenetics is a mechanism that regulates how genes express themselves independently of the DNA sequence or code, relying instead on the chemical modifications of DNA. Epigenetic tags act as “gatekeepers” blocking or allowing access to a gene’s ‘on’ switch. Scientists have long believed that environmental and genetic factors independently contribute to T2D risk; yet, several lines of evidence suggest that epigenetics bridges these two factors. Epigenetic changes can either be inherited or accumulated throughout our lifetime. But, most importantly, they can be reversible. That means, even if we do carry genetic risk factors that make us more susceptible to developing T2D, it is highly likely that changes in our lifestyle, like increasing our physical activity levels and/or eating healthier, can play a protective role through epigenetic mechanisms.

Diabetes in the Middle East – Our Model

Differences in diabetes risk across populations cannot be explained solely by environmental risk factors. In other words, it is the interaction between our environment and our genes that determines whether we remain healthy or develop disease. In some populations, like the Gulf, their genes might predispose them to diabetes, but it is the environmental factors that tip the scale one way or the other. Despite the lack of scientific research, it is likely that the populations in the Middle East, particularly in the Gulf, are at a higher risk of developing T2D with lower BMI ranges, or smaller changes in their diet, or smaller decreases in their physical activity levels. On the other hand, that could also mean that lifestyle interventions can be very effective and promising in these populations in preventing and delaying the onset of diabetes. In the end, this could be some good news for T2D patients and doctors in the Gulf. We can do something about it. Exercise more and eat healthier.

Ongoing efforts of healthcare givers and public health initiatives in combating the burgeoning problem of obesity and diabetes in the Middle East cannot be undermined. These include providing early diagnosis of diabetes, high quality treatment, and addressing people’s lack of physical activity and poor diet choices. Today, compared to 10 years ago, people in the Middle East are better educated about diabetes, and more aware of what they should and what they should not do; we try to walk more, eat healthier, watch our weight, and try to exercise.

In the UAE, since 2006, ICLDC in Abu Dhabi, a leading diabetes centre, has developed a public health initiative, which is intended to reach all levels of the UAE society using multiple pillars: Walk for life, Play for Life, Eat for Life and Cook for Life. The Walk for Life is an annual 5K walkathon for the community, which takes place in November every year, and attracts more than 20,000 people. This initiative aims to inspire people to walk, build walking communities and encourage healthy lifestyles. These are impressive promising steps in the right direction, and more is yet to come from the UAE and other nations in the region.

In an interview with Daily Dose, he says: “Innovation makes it more and more possible to deliver care immediately. It is transforming the way you contact and converse with doctors. One of the biggest problems patients face when they have an ailment is that they don’t know where or whom to go to? They have to move from their location in order to get immediate attention.

“This is where telemedicine comes in. It doesn’t require the patient to move and will surely revolutionise the healthcare landscape. It is a known fact that the more you wait, the worse the problem can become. Treating the patient early results in reduced costs as well as in delivering effective care. Innovation delivers healthcare in the homes of the patient, and right in their hands.”

The second change, he highlights, that innovation in healthcare will bring about is that it will reduce errors through digitisation. Having digital records and technologies such as Artificial Intelligence (AI) will enable doctors in having a clear vision and making informed choices.

At the show, GSD is hosting hands-on-training sessions for cardiologists and is bringing renowned physicians to demonstrate Italian know-how to doctors in the region. GSD also hosted the first-ever Global Health Pioneer Awards, in association with UAE Genetics Disease Association and Arab Health, on the eve of the exhibition.

Rotelli says: “Arab Health is interesting for us and for everyone attending due to two factors. The first is that visitors get to discover the level of technology available in different countries and to help us understand where we should aim in 2019/2020. It helps us comprehend where healthcare is going and gives us an insight into where the biggest companies in the industry, be it pharma or hospitals, are headed in the near future. We don’t just want to witness change; we want to be a part of it. The event is also a great platform for entering into Memorandum of Understandings (MoUs) with leading institutions in the region.”

Last year, GSD started teaching and training programmes in the UAE, through GSD Healthcare, its UAE arm. These programmes, held in association with the Dubai Health Authority (DHA), bring some of the most renowned surgeons to pass on their expertise in the region. Its training centre in Dubai, targets medical and healthcare professionals from the GCC and Middle Eastern region to provide high quality, accredited courses in a multitude of medical, surgical and healthcare management topics.

He says: “We will continue with this approach of our experts visiting and training doctors in the region, as we believe the best investment is investing in people. We also hope to work with local institutions beyond training and collaborate in building efficient hospital management systems as well as engage in cultural exchanges. However, I would like to reiterate that our goal is to create know-how between the region and Italy.”

Defining the Perfect Healthcare Delivery System

According to Rotelli, the keywords that define a comprehensive healthcare delivery system are integration and transparency of information.

“Most countries are strong in primary care, general practitioners (GP) etc., but not one institution can solve a problem 360-degrees,” he explains. “The perfect healthcare system, according to me, is based on digital medical records that can be accessed by any doctor, anywhere. By just clicking a button, a physician can have all the required details and avoid mistakes. Then there should also be a system that helps GPs, hospitals as well as outpatient clinics to share everything about the patient and exchange opinions with each other.”

Furthermore, he believes that the best system is when the government pays for healthcare but it is managed privately, so that it creates competition not in terms of price, but only in terms of quality. “For example, in Italy’s healthcare system, the competition is on quality. The patient will go to the best doctor but at the same time, it will be at a minimal cost. This is why public-private partnership is key in building an efficient industry,” he adds.

Rotelli also stresses the importance of medical research. Even though healthcare has advanced tremendously over the years, he feels that we are still very far away from knowing about the human body or how genetics work.

He emphasises: “For example, we don’t know what causes headaches? We know why it’s caused but not what causes it. So, even though the advancements seem impressive, we don’t know a lot.

“In European countries, investment in medical research is going down. But without believing in medical research you stop to progress and start to regress. For example, even though these concepts are being discussed in the industry, it will still take the next 10 to 20 years for personalised medicine to be the next big trend, as not much is yet known about it. Focusing on and investing in medical research is definitely a central topic for us.”

On a parting note, he shares a profound piece of advice he received from his father: “Companies and hospitals are not made of something complicated, they are made of human beings. They exist because people are working in it. The buildings and technology are not as important as the people inside it. What is important is the know-how.

“We have doctors who go to countries in Africa that don’t have fancy buildings or equipment but the output they deliver is the same they would in our state-of-the-art facilities in Italy. Of course, we cannot disregard the importance of technology and buildings, but if you want to cure, you need to invest in the know-how of the people. To be a good healthcare manager, you need to focus on training people.”

Depression is the single leading cause of disability worldwide, according to the World Health Organization (WHO), and data from the Centers for Disease Control and Prevention (CDC) suggest that one in five children in the U.S. between the ages of three and 16 have a diagnosable mental, emotional or behavioural health disorder. Suicide is the 10th leading cause of death in the U.S. at an annual cost of $69 billion, and rates are on the rise.

The increase in suicide is observed worldwide, with a global rate of 10.7 per 100,000 in 2015. Despite recognition of increases in mental healthcare needs, in the U.S., only approximately 20 per cent of children and adolescents will be diagnosed and receive care. With suicide rates higher than ever before, it is our responsibility, as healthcare providers and healthcare systems, to develop mental health programmes for our communities.

In 2013, the WHO enacted a comprehensive mental health action plan, with primary objectives including strengthening leadership and governance for mental health, providing a comprehensive, integrated and responsive mental healthcare system across settings, implementing strategies for promotion and prevention, and strengthening evidence and research focused on mental health. This action plan is aspirational, even in 2019, with continuing barriers to mental healthcare limiting progress.

A lack of well-trained providers across the continuum who understand evidence-based practices limits mental health services for children and adolescents in need. Continued evidence shows cognitive behavioural therapy treatments and psychotropic medications, in combination, are the most effective treatment for many mental health diagnoses. Daily barriers, including reduced reimbursement for services, few resources, and limited time and space, leave practitioners few opportunities to focus on a comprehensive approach to services that includes prevention, early intervention and specialised care.

To expand access and develop prevention programmes, primary care providers have taken on a greater role in mental healthcare. However, primary care providers continue to be undertrained in mental health diagnosis and treatment. Residency curriculum and primary care mental health programmes are increasing attention on mental health, which results in increased empowerment of primary care providers to work to prevent mental health concerns.

However, schools and educators play a large role in prevention as well, with an additional need for mental health focused curriculum needed for educators, administrators and school nurses. Schools are increasingly focusing on positive behavioural, emotional and social support, and these programmes are necessary for establishing pro-social behaviours.

Identifying Risks

Early intervention and screening have the opportunity to reduce costs by avoiding more specialised treatments in the future and educate children and parents on warning signs that will allow for earlier diagnosis. Maternal mental health and general health plays a large role, as this early relationship sets the stage for future self-regulation and emotional development. Identification of those most at risk, such as those who have experienced childhood maltreatment (including exposure to violence and other traumatic events), discrimination, bullying, malnutrition and other stressful events, allows for appropriate early intervention and the potential for improvements in mental wellbeing. Early identification of children and families at risk for mental health diagnosis is likely to significantly reduce the number of children diagnosed later.

Hospital systems find themselves underprepared for increasing rates of mental health concerns. Children and adolescents are presenting more frequently to emergency centres with mental health and psychiatric concerns, and the emergency centre physicians and care teams often have very limited training in mental health and limited resources to address these concerns. Children’s hospitals in the U.S. are beginning to open psychiatric emergency centres, with an opportunity to address concerns rapidly and urgently. Yet, these sites remain limited, and necessitate the full continuum of mental healthcare, including inpatient, residential, intensive day treatment and outpatient services, which have limited access. Evidence-based intervention by highly trained and qualified specialists remains a key barrier and, at the same time, a necessity for access to appropriate mental health services for children and adolescents.

Despite increasing focus on mental health diagnosis and treatment worldwide, the full continuum of mental health interventions remains limited. A well-trained, specialised and fairly compensated mental health provider workforce remains a primary barrier. Specialised treatment modalities, including psychotherapy, psychological testing, medication management and family education are key to providing an appropriate continuum of care. As interventions intensify, high quality residential treatment facilities are key, as well as therapeutic homes for more severe mental health concerns. While most children and adolescents will not require this level of care, worldwide systems remain underprepared for the increasing complexity of mental health presentations in children and adolescents. With an ever-increasing need for mental health services, and an ongoing need for an appropriately trained and specialised workforce, in high acuity health care settings, we remain underprepared worldwide to meet these needs.

More than ever before, individuals are sharing their mental health diagnoses and stories. This reduction in stigma assists with parents and adolescents seeking care when needed; however, additional education on early signs, symptoms, and appropriate treatment is necessary to improve overall outcomes and improve quality of life. Capacity to identify and treat those in need necessitates collaboration across multiple systems and individuals. Healthcare providers, both primary care and specialist, must be prepared to work with systems that are typically separate, including schools, government agencies and communities. For healthcare systems, this may mean cross-system communication, sharing of information, and multi-tier treatment systems that cross-cut multiple systems and environments for each child’s daily life. This comprehensive level of care may be what it takes to address, and in turn, decrease, mental health diagnoses in children and adolescents.

Early identification and appropriate treatment for child and adolescent mental health concerns is necessary to prevent later adult mental health disorders. Approximately one-half of all adult mental health disorders are diagnosed before age 14, and early diagnosis and treatment is necessary for prevention of life-long mental health conditions that can result in disability, under-education and unemployment.

Long-term, systematic change will require intensive time and training. Future goals for development of mental health treatment programmes must include a family-focused approach, by a well-trained workforce that spans the treatment continuum, close to the family’s home. Healthcare providers and hospital systems must take initiative in development of innovative strategies for prevention, early intervention and specialised care. Increased focus worldwide on mental health must be a primary objective for the future in order to ensure the overall health and wellbeing of future generations.