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In 2011-2012, the World Economic Forum convened a group of experts, scientists and policy-makers to consider the implications of brain science, mental disorders and the emerging field of cognitive science for the economy and society. The Council – comprised of figures from all over the world, including the USA, Europe, Africa, Latin America and Asia – represented several different approaches to the brain, including neuroscientists and researchers, psychologists, public health practitioners, medical device manufacturers, and pharmaceutical companies. With complementary and – at times – differing points of view, the Council produced a highly rich, 360-degree review of brain science in today’s economy, as well as an objective assessment of the potential of the cognitive sciences.
Above all, the Council agreed two key points: first, given the prevalence and high costs of mental disorders worldwide (at 35% of the cost of non-communicable diseases (NCDs), overall), governments, research centres and the private sector must improve and deepen their collaboration to bring new treatments to patients; second, while neuroscience and cognitive science hold important potential for improving the way citizens, governments and companies make choices, learn, or respond to their environment, a concerted effort is required by all stakeholders to translate this potential into practical strategies to serve the public interest.
The Council hopes its deliberations, summarized in this report, will raise awareness among the network of the World Economic Forum’s stakeholders of the importance of the brain sciences and the imperative of giving priority to continued research and development in this field.
The brain is the organ of thought, emotion, social interaction and decision-making. Healthy brain function is, therefore, an essential foundation for human development, for learning in school and throughout life, and for effective functioning in the workplace and in society more generally. Progress in understanding the structure and function of the brain, as well as the genetic and environmental bases of brain development, is providing significant new insights into individual and social behaviour and into the causes and treatments of brain disorders.1
Less well recognized is that brain science can help societies influence the behavioural drivers that spread communicable diseases and lead people to take risks exposing them to a diverse array of non-communicable diseases (NCDs) that are now increasingly common globally, such as obesity, diabetes, and heart disease. Finally, brain science can make a major contribution to national and transnational well-being. Globalization, competition, urbanization, and interconnectedness have profoundly altered the way people live. These powerful forces for change can bring great benefits, but can also serve as potent stressors acting, via the brain, to produce adverse effects on individuals, families, and societies.
Brain disorders produce not only suffering, but also significantly depress both human capital formation and productivity. The effect of brain disorders on societies and economies has been partly quantified by modern measures of disease burden (measures of human capital formation are still rudimentary). Disability Adjusted Life Years (DALYs) is a measure developed by the World Bank and World Health Organization (WHO) and quantifies the effects of disease not only on premature mortality, but also on the number of years of healthy life lost to disability. While some brain disorders – especially depression, schizophrenia, and addictive disorders – contribute to premature mortality through increasing the risk of suicide, and others – such as stroke – can be direct causes of death, brain disorders generally decrease quality of life because of their significant contribution to disability. According to recent WHO statistics, brain disorders in aggregate, are the largest contributors to disease burden in advanced market economies, and the leading cause of disability worldwide. Corroborating these findings by a different methodology, the 2011 study by the World Economic Forum and Harvard School of Public Health on NCDs, found that mental illnesses (a subset of brain disorders that primarily affect thought, emotion, and control of behaviour) represent the single greatest contributor to lost economic output, accounting for 35% of the overall costs of NCDs.
Indeed, common disorders, such as depression, contribute to the onset and poor outcome of other NCDs, partly by direct physiological means, and partly by interfering with healthy behaviours and treatment adherence. It has justly been stated that there is no health without mental health. Because of the early onset and chronic or recurrent course of many brain disorders – such as autism, epilepsy, mood and anxiety disorders, ADHD, learning disorders, and schizophrenia – they also create a staggering drag on human capital formation and thus an enormous long-term cost to societies.
Despite this economic data, widely available, for more than a decade, brain disorders often remain invisible, stigmatized, or both. Many developed and most developing countries lack adequate systems for diagnosis and treatment, such as access to essential pharmaceuticals and psychosocial treatments. In some countries there is discrimination with respect to insurance coverage. There is enough evidence (from WHO and other data sources) to show that the investments made by governments, the private sector, and civil society for the treatment of brain disorders, ranging from depression to neurodegenerative disorders such as Parkinson’s disease and Alzheimer’s disease, are disproportionately low compared to their relatively high impact on individuals, families, and the economic measures of disease burden. The decision in 2011, by a high-level meeting on NCDs convened by the United Nations General Assembly to specifically exclude brain disorders, is a case in point.
Research on brain disorders, and especially on mental disorders, remains fragmented and underfunded compared with other areas of biomedicine (based on investment/DALY). Moreover, the past three years has seen industry withdrawing research effort on brain disorders as “too difficult”, despite enormous unmet medical need and large global markets. The resulting decrease in investment has been substantial, significantly reducing the likelihood of developing much needed new treatments.
In conclusion, there is growing global evidence of the toll taken by brain disorders, while societies continue to under-invest in research and treatment. It is against this backdrop that the Global Agenda Council on Brain and Cognitive Sciences deliberated on how best to address these crucial issues. We propose these six initial areas for attention:
1. Stigma and Ignorance
It is well documented that brain disorders – including the mental disorders, epilepsy and neurodegenerative disorders – are often stigmatized. This means that people with signs of these disorders may be ridiculed, feared, blamed, or even deprived of human rights depending on the context. Moreover, the inaccessibility of the human brain compared with other organs, the false belief that brain mechanisms are susceptible to introspection and willpower, and the biological complexity of neurological diseases means that brain disorders are often de-prioritized or even ignored in health systems. There are many myths surrounding mental disorders, e.g., that they are not “real”, that they cannot be diagnosed reliably, or that there are no treatments available. Although these myths are demonstrably false, they continue to influence attitudes and policy. The stigmatization of addictive disorders has, in many societies, tilted the balance away from treatment towards blame and excessive criminalization. The stigma and ignorance that surround brain disorders and their sufferers may play a significant role in their not receiving sufficient attention, and thus deserve greater examination by the Council.
The worldwide campaign for HIV resources provides a positive example of how tackling stigma can be effective in raising awareness and increasing resources and support for research and treatment of disease. Likewise, reducing the stigma and paying attention to human rights issues surrounding brain disorders would help not only sufferers and their families (care-givers often have to limit their participation in the workforce), but also aid in establishing research and treatment programs, thereby giving those impacted by mental disorders a chance to lead more productive lives.
2. Human Capital
As noted, brain disorders contribute disproportionately to DALYs through disability, which has been increasingly well measured. Given the early onset of many brain disorders – such as ADHD, autism, learning disabilities, anxiety disorders, and others – there is also a marked, albeit poorly measured, drag on school performance and the ability to learn, and thus on human capital formation and future economic performance. In some developing countries, perinatal malnutrition, deficits in perinatal care, and infectious diseases, such as cerebral malaria, create high rates of early onset brain disorders. Better measurement and recognition of such conditions appear to be critical not only to improve economic performance, but the well-being of individuals and families.
3. Demographic shifts
Brain disorders are common in aggregate; as noted, many begin early in life, and tend to run a chronic or relapsing course. Late onset brain disorders – late-life depression, stroke, Alzheimer’s disease, and Parkinson’s disease – are increasingly prevalent and costly as the demographic structure of many countries changes toward an older population. Indeed, with the world’s population now ageing dramatically, the impact of neurodegenerative disorders, such as Alzheimer’s disease, on individuals, their families and economies, is potentially large enough to overwhelm health and social care systems in some countries.
4. Reinvigorating drug development
Central Nervous System (CNS) drugs, the term most often used in industry to describe the drugs that treat brain disorders, include antidepressants, antipsychotic drugs, and anticonvulsant drugs, as well as benzodiazepines, and related drugs used to treat sleep and anxiety disorders. For many decades these have been among the leading generators of revenue for the pharmaceutical industry, but in the past two to three years, many large companies have exited this area of drug discovery and research. They have done so because the existing models have been tapped dry, and there has been insufficient investment from public and private sources on the difficult challenges of new models. There is a dearth of molecular targets for new CNS drug discovery, current animal models have failed to predict drug efficacy, and clinical trials are still based on subjective outcomes rather than biomarkers. Industry is, therefore, making the business decision to invest elsewhere, leaving many millions of people, who are inadequately served by current treatments, without near-term hope. The design and implementation of effective public-private partnerships to decrease the risk in developing treatments for autism, schizophrenia, bipolar disorder, and Alzheimer’s disease, among others, is a pressing matter.
5. Innovative application of cognitive neuroscience to assist persons with brain disorders
The emphasis on drug development should not obscure existing non-pharmacological approaches and interventions that influence brain function and facilitate functional recovery, such as those at the interface of cognitive science and neuroscience. Likewise, improving diagnostics and biomarkers could potentially help in the design of clinical trials, and also help to streamline regulatory processes and give greater confidence to insurers regarding diagnoses.
Substantial cognitive science knowledge exists to assist persons with brain disorders, their families and communities. However, only a tiny proportion of it is leveraged by current treatments, even in advanced market economies. Electronic and information technology should be harnessed to develop products that can be made available as public goods, to the benefit of large numbers of people, at a very low cost. These products can greatly enhance diagnosis, treatment and rehabilitation of persons with mental and neurological disorders.
6. The neural basis of decision-making and behaviour
Research results show how cognitive functions can influence the ways humans act and react. The public’s imagination has been captured by books such as Freakonomics or Nudge, leading to growing interest in the applications of cognitive science across a wide range of interests. As the science continues to mature, however, it is important to manage expectations regarding its effectiveness, and sort the robust from the speculative.
Governments have become interested in behavioural economics, perceiving an attractive combination of free markets with some directional control. In addition, certain specific disciplines have quickly adopted cognitive science techniques to achieve their objectives, such as education, personal finance, judicial and penal systems, and healthcare, particularly in tackling non-communicable diseases. Businesses engaged in product development, marketing and retail have long used cognitive techniques to drive consumption, and while this work has been largely empirical (and arguably poorly focused scientifically) it has undoubtedly been effective and commercially (if not always scientifically) rigorous.
Several avenues of research are currently showing great promise. There is great potential in understanding the consequences of decision-making processes and behaviours that emerge in groups and populations (as well as the feedback of such emergent mass behaviours on individual economic consumption). Understanding how information spreads, and how individuals and groups may be influenced is readily applicable to the shaping of healthier decisions. An early example of a population-wide programme is Weqaya in Abu Dhabi, where NCDs are being tackled across the population through individual screening, integrated data systems, and personalised feedback.
Likewise, cognitive research has shown ways in which business leaders and organizations can create brighter working environments and better personal interactions within their organizations, so as to produce healthier behaviours and happier workers. The use of technology to connect people who might be located far from their colleagues releases oxytocin, improving employees’ well-being and making them more productive. Such approaches ultimately reduce ill-health and disease, and have immense potential for cost-savings in public health.
However, amid all the expectations, it is important to recognise that the field of cognitive science is still emerging and that some of the more exuberant expectations regarding its near-term potential may need to be tempered to avoid disappointment.
To have an impact, particularly in an area as rich and diverse as the brain and cognitive Sciences, we realized that our Council would need to focus its attention. We selected four of the six topics in which to make specific recommendations.
1. Stigma and ignorance
The scale of mental disorders has been clearly and consistently documented for at least two decades, and yet substantive progress on mobilising resources to tackle these conditions has been limited and slow relative to other disorders. Why?
We suggest that the systematic failure of global, national and local structures to recognise and address mental disorders represents a form of stigma, and that this is underpinned by a discrete set of cognitive processes. Further, we believe that characterization of these processes may be a first step to overcoming this stigma. Clearly, it would be a strong and resonant demonstration of the power of the cognitive approach if it could address one of the challenges in its own backyard.
2. Stimulating Investment in drug discovery and development for brain disorders
The major requirement for industry to re-engage in CNS drug development is to reduce the risk of failure, making brain disorders a relatively more favourable area of investment. Current global discussions on new models of drug discovery and development must be accelerated and made more effective. Ideas are generally based on public-private partnerships that involve academia, NGOs, industry, and government. Such partnerships should focus on identifying new molecular targets, new models for testing safety and efficacy, and new biomarkers for diagnosis and clinical trials.
It will be critical to involve regulators in the development of such partnerships right from the beginning to help foster innovation on the greatest challenges and areas of highest disease burden.2 It is encouraging that others are already working to promote such ideas, including the Alzheimer’s Disease Neuroimaging Initiative, the Neuroscience Forum of the US Institute of Medicine (a component of the US National Academies), One Mind for Brain Research, and an Alzheimer’s disease consortium sponsored by the New York Academy of Science. Building on these examples, the Council recommends that policy-makers, companies and research institutions:
a. Boost Innovation and Science
Investment in mental disorders clearly lags behind other areas such as cancer and cardiovascular disease . National governments should make CNS research a priority. Another source of innovation could be the creation of specialized European or international programs to bring together excellence in CNS science from all over the world. Specialized investment funds supported, for example, by the European Investment Fund (EIF) or other national or international organizations, could be created to fund innovation in this field.
The innovation drive created by additional financial resources should spur development in the pharmaceutical/biotech industries as many more new and promising concepts become available to market.
b. Accelerate clinical development of therapeutics
Lengthy and expensive clinical development processes could be improved by better selection of patients for clinical trials and new clinical trial designs. Better patient selection will require the identification of biomarkers, perhaps via public-private partnerships, and their acceptance by regulators. Indeed all attempts to accelerate development will require the participation of regulators from the beginning of the process.
c. Build incentive systems
The system of incentives for risk-taking and innovation must be thoroughly examined. Proposed incentive systems include tax transfers for industries and universities dedicated to drug development for brain disorders for which current treatments are far from adequate (e.g., Alzheimer’s disease). Likewise, more countries might consider tax breaks for individuals who support research into CNS diseases, e.g., as is done in the United Kingdom (http://www.hmrc.gov.uk/eis/guidance.pdf).
Other measures could include involving national pension plans and health insurance schemes in the development cost of research set against a future share in their revenues. Industry could also be granted a fair price assessment based on value contribution, or special intellectual property protection in addition to a parallel trade protection, to compensate for the long development time of new drugs and therapies.
Another range of incentives that could be considered are those to allow reimbursement for new therapies. Today, these are subject to a two-stage system of approval; first by regulators, and second by those who will pay for the incentives. Succeeding in stage one, difficult enough in itself, does not guarantee success in stage two. And very often, different degrees of clinical evidence are required by these two audiences, again increasing the investment required to successfully bring a new therapy to market. This is especially true for novel treatments (e.g., biologics, devices, etc) compared to (often ineffective) conventional medical therapies.
Meanwhile, although drugs are clearly the most widely prescribed therapies for CNS disorders, the discussion should not be limited solely to pharma-based solutions. Promising new therapies for severe, treatment resistant CNS disorders also include medical devices (e.g., Deep Brain Stimulators).
3. Implementing cognitive science applications for brain health
While drug and therapy research is under way, practitioners should not neglect the potential of existing measures using cognitive methods for treating and improving the quality of life of the mentally ill. These interventions may be cost effective and quick – two aspects of healthcare policy important in fast-growing, developing economies. Two examples of successful cognitive approaches are:
a. Identifying and treating depression
Simple easy-to-use algorithms exist to screen people for the presence of depressive disorders, to assess the severity of their condition, and to suggest further action, such as referral to the health services. However, these are not used widely enough. Technological advances have offered the possibility that these simple assessments can deliver effective screening and tools for self-administered psychological management of mood states. These tools could be distributed to millions of sufferers using computers, websites and mobile phones. What is needed is to package the material effectively and make it easily accessible using public and corporate platforms.
b. Improving communication and the quality of life of persons with cognitive dysfunction/decline
An increasing number of people will be living with cognitive deficit, decline or impairment of some kind. These will include persons with intellectual disabilities – such as autism, dyslexia and dementia. There are well documented ways in which cognitive assistance could be provided using electronic and information technology to improve their capacity to learn, retain information, and carry out day to day tasks. These techniques are often simple and generic (requiring little or no customization) and could be packaged innovatively and attractively, and delivered using public and corporate platforms at very little or no cost.
4. The neural basis of decision-making and behaviour
Given the complexity of human cognition and of the drivers of decision-making, it is important to anchor progress in the field of cognitive science in both scientific method and empiricism. Practical fieldwork can help to identify what works in practice, testing models while building a toolkit of applications that have been shown to work. Robust measurement of applicability and effectiveness is at the heart of professionalizing such empirical fieldwork. Moreover, modern and ubiquitous mobile devices provide new ways to observe and record individual behaviours and characteristics, and the Internet increasingly offers the ability to compile and to distribute the results of research. As with the creation of the World Wide Web in the early 1990s, data standards are important to ensure comparability. It now appears to be both important and practical to identify, collate and disseminate valid approaches to cognitive science to help grow a broad range of societal benefits.
As the science progresses and professionalizes, researchers and policy-makers should consider the ethical aspects surrounding newly emerging knowledge regarding the brain and its functions. Increasingly sophisticated use of science in marketing, plus advances in IT (ubiquitous computing, social networks, and mobile technology) can have positive or negative applications. “Positive” phenomena might include stimulating charitable giving by the public following natural disasters (and perhaps future pandemics of serious diseases). We have seen decades of effective marketing of goods and services focused on building and exploiting consumer “desires” rather than “needs”. Emerging science and technologies may substantially strengthen the power of such marketing, and perhaps fundamentally shift the balance of marketing power to sellers, causing issues for consumers. In addition, there is potential for governments and other groups to drive large-scale behaviours, with unpredictable consequences. In this context, ethics must inform approaches to research and the application of cognitive science.
The Council proposes to host a targeted dialogue, and co-ordinate research and fieldwork, through a World Economic Forum platform to explore further the potential of the application of cognitive science in the following fields.
Obtain a deeper understanding of how behavioural and brain sciences can help to drive positive outcomes in key sectors (e.g., health, education, and start-up enterprise); explain the emergence of certain individual and social issues ( e.g., consumer debt, crime, and civil unrest); improve the discrimination of sound approaches; and generate ideas for building systematic learning across sectors
b. Manufacturer/Retailer/Consumer behaviour
Develop more engaging goods and services, and new approaches to building customer loyalty and encouraging sustainable consumption; take the opportunity to enhance decades of empirical learning-by-doing with cutting-edge theoretical model.
Provide access to real-world data from applied fieldwork across multiple sectors
Understand cognitive factors in crime and the consequences for the legal system; transition from legal systems based on retribution to systems based on prevention and remediation
e. Climate change
Examine consumption-based approaches to understanding climate change and how changing consumer behaviour could have a positive impact on reducing carbon emissions
The results of this initiative would culminate in a report defining better, shared, interdisciplinary understanding of the practical applications of the cognitive sciences, helping to focus stakeholders on what really works.
The opinions expressed here are those of the individual members of the Council and not of the World Economic Forum or any institutions to which they are affiliated.