This is the conclusion of a scoping review published in Health Policy by a team of researchers from the Swiss Tropical and Public Health Institute, the University of Basel, Columbia University, and Maastricht University.

Of a sample of 394 articles from three international bibliographic databases (Medline, PsycInfo, and ERIC), all published between 2000 and 2024, researchers found just seven studies addressing the topic.

What is transformational leadership?

1. Fostering collective action: inspires people to look beyond their personal interests in favor of a common goal.

2. Stimulating innovation: encourages people to question established assumptions and to think creatively.

3. Focusing on the long term: prioritizes sustainable development over immediate results, increasing motivation and engagement.

4. Evidence-based decision-making: creates environments where choices are guided by data, even in situations of crisis or uncertainty.

5. Conceptual distinction: contrasts with transactional leadership (based on reward/punishment) and purely hierarchical models.

Lack of evidence and standards

The seven studies were conducted across a wide range of locations: four in the United States, one in New Zealand and Bangladesh, one in Ireland, and one in Iran and the Middle East. 

Only one used a validated tool to measure leadership skills: the Multifactor Leadership Questionnaire (MLQ). The rest relied on reflective or descriptive assessments, limiting the comparability and transferability of the findings.

The authors acknowledge that the evidence remains scarce and diverse, and that more robust assessment tools need to be developed, in addition to expanding research to different populations and social and geographic contexts.

Transformational leadership and alternative models

Four of the seven studies focused specifically on transformational leadership, a management style that seeks to inspire, motivate, and engage teams around shared goals. 

The other three adopted alternative models, without a single theoretical basis:

• Peter Senge’s Shared Vision model
• Learning communities
• The Nine Best Practices for Leadership Training framework

The diverse range of approaches and absence of a single dominant model outside transformational leadership reinforce the authors’ conclusion that the field has yet to reach a consensus on best practices.

Despite these differences, the programs shared commonalities in some key areas. The most frequently used teaching techniques were group discussions, collaborative learning, and experiential learning, which appeared in all seven studies. 

The most frequently covered topics were:

• Leadership development: addressed in all 7 studies
• Personal and professional growth: 6 out of 7 studies
• Teamwork and collaboration: 6 out of 7 studies
• Leadership models and frameworks: 6 out of 7 studies

Mentoring: the approach with the greatest measurable impact

Of all the interventions analyzed, mentoring produced the most robust evidence. In just nine weeks, the M³ program (Multi-Modality Mentoring) resulted in a statistically significant improvement in transformational leadership among 54 research fellows studying public health, pharmacy, and medicine at US universities.

Their average MLQ score increased from 61.88 to 65.59 (from a total of 80 points). The study authors calculated the effect size at Cohen’s d = 0.49, which they described as “substantial and desirable,” especially considering the program’s short duration.

According to the authors, mentoring stands out because it can be adapted to the needs and circumstances of each student. A PhD is the ideal time for this type of training: students are close to entering the job market, but they are still receptive to innovative ideas.

What does it take to lead a research group?

An ongoing issue

The lack of leadership training in health-related fields is nothing new. In 1988, the Institute of Medicine (IOM) published The Future of Public Health, a report containing a warning that remains relevant to this day: “Today the need for leaders is too great to leave their emergence to chance.”

Almost four decades later, the lack of studies on the subject suggests that the issue remains structural. The 2025 review is itself a sign of this, with the authors identifying just seven relevant studies from 24 years of scientific literature.

Next steps for future research

The authors suggest that future research should investigate whether certain leadership skills are particularly important in specific populations and social and geographic contexts, and how best to develop them. 

They also recommend comparative and longitudinal studies to identify adaptable models and measure the long-term impact of leadership training on PhD graduates.

When the most crucial competencies have been identified for each situation, transformational leadership training could be implemented as a central element in educational strategies, with the aim of creating more resilient and equitable health systems—including leadership on issues such as climate change, food security, environmental protection, and social policy.

How to prepare for leadership during your PhD

1. Look for a structured mentoring program: Mentoring is seen as the most effective intervention—programs as short as 9 weeks with personalized mentoring showed measurable gains in transformational leadership (Cohen’s d = 0.49). Look for fellowships, graduate programs, or institutional networks that offer this form of support.

2. Participate in active learning methodologies: Group discussions, real-world problem-solving, and collaborative feedback were present in all seven of the studies analyzed. These practices help develop self-awareness, communication, and decision-making skills, which are central to transformational leadership.

3. Pursue practical experiences beyond academia: The authors recommend seeking out internships and projects at government agencies, NGOs, and in the wider community. These experiences build competencies that are difficult to develop in a purely academic environment, such as the ability to adapt to complex situations and motivate people.

4. Cultivate a collaborative network: Collaborative learning has been identified as one of the key drivers of leadership development. Cultivating relationships with peers, participating in international networks, and contributing to collaborative scientific papers can all help develop leadership skills throughout a doctoral program.

5. Invest in self-awareness and self-reflection: All the programs analyzed included some form of reflection on one’s own leadership style. The authors highlight self-awareness of one’s own strengths and limitations as a prerequisite for exerting a positive influence on teams and systems.

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The study drew on cancer registry data from all 50 US states. To assess the influence of birth country, the researchers focused on 13 states with complete information on patients’ origins. In total, they identified 3,228 cases diagnosed between 2005 and 2022.

Among non-Hispanic Caribbean immigrants, the incidence reached 14.1 new cases per million people—comparable to rates reported in historically endemic regions such as Japan, sub-Saharan Africa, and parts of South America. The highest rate was observed among people born in Grenada, at 33.7 cases per million. By contrast, among individuals born in the United States and Canada, the incidence was just 0.4 cases per million. 

Racial disparities in survival rates

The five-year survival rate was calculated using data from New York and Florida—the only states with complete follow-up information—and averaged 23.8%. Survival varied substantially by race, ethnicity, and place of birth:

• Non-Hispanic Whites: 38.9% 
• Hispanics: 26.1% 
• US-born non-Hispanic Blacks: 19.6%
• Caribbean-born non-Hispanic Blacks: 14.5%

The disparity is not merely statistical. The analysis showed that non-Hispanic Black individuals born in the Caribbean face more than twice the risk of dying specifically from ATLL compared with non-Hispanic White individuals—a gap that persists even after accounting for factors such as age, gender, and disease subtype at diagnosis.

Latent virus, late cancer

ATLL almost always begins the same way: a baby becomes infected during breastfeeding by a mother carrying the virus. HTLV-1 invades the body’s immune cells and remains dormant there—silent and symptom-free—for four to five decades, gradually accumulating genetic damage that, in a small fraction of cases, ultimately leads to cancer.

The disease typically emerges between the ages of 50 and 60. Only 2% to 5% of infected individuals develop ATLL.

Among adults, the virus can also be transmitted through sexual contact or blood exposure, much like HIV. The US Center for Disease Control and Prevention (CDC) recommends replacing breastfeeding with infant formula when maternal HTLV-1 infection has been confirmed. One important detail is that PrEP and other HIV-prevention strategies do not protect against HTLV-1, making maternal screening the only effective way to interrupt the chain of transmission that gives rise to the cancer.

Because it originates almost exclusively from infection acquired in early childhood, ATLL is, according to the authors, one of the few fundamentally preventable blood cancers. 

The hidden problem: misdiagnosis

The disease’s invisibility has a second dimension. ATLL is frequently mistaken for other types of T-cell cancer, particularly peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS), a category used when physicians are unable to identify a more specific subtype. The reason is straightforward: testing for HTLV-1 is not routinely performed when T-cell lymphoma is suspected, especially among patients from immigrant communities.

The researchers estimated the impact of this diagnostic confusion. After reclassifying cases likely to have been misdiagnosed, the incidence of ATLL among non-Hispanic Caribbean immigrants would rise from 14.1 to 22.7 cases per million—comparable to rates in southwestern Japan, historically the region most affected by the disease worldwide. Among people born in Grenada, the incidence could reach 59 cases per million, surpassing even that of Japan.

Japan as a prevention model

Japan has demonstrated that the disease can be reduced. For more than three decades, the country screened pregnant women for HTLV-1 and advised infected mothers not to breastfeed. The results took time to emerge, but they eventually did: starting in 2013, the number of new ATLL cases started to decline in Kagoshima, one of the regions most heavily affected by the disease.

The United States has yet to follow that path. HTLV-1 testing is performed only for blood donations, not as part of prenatal screening. The authors propose a practical alternative: rather than screening the entire population—which would likely be less cost-effective given the virus’s low overall prevalence in the country—they recommend focusing on mothers born in non-Hispanic Caribbean nations, where the risk is demonstrably high.

The need for action is urgent. Children infected during the 1990s and 2000s are now entering the age range at which ATLL typically develops. Without intervention, the number of cases is expected to continue rising.

Brazil: silent endemic

Brazil tests for HTLV-1 in blood donors and pregnant women, but coverage remains insufficient. The disease is likely more common than official figures suggest, simply because so few cases are ultimately diagnosed. An abstract presented at the 2025 Brazilian Congress of Hematology, based on data from Rio de Janeiro’s Gaffrée and Guinle University Hospital (HUGG/UNIRIO), identified only six confirmed cases of ATLL over a ten-year period at a referral outpatient clinic in the city. All of the patients were women, with a mean age of 58, and they survived an average of just 13 months after diagnosis—far worse than the 23.8% five-year survival rate reported in the United States, where the disease is at least more likely to be recognized.

High HTLV-1 prevalence has already been documented in regions with large Black populations,  such as Salvador, a pattern partly explained by the African ancestry of a portion of the population, as Central and West Africa have long been recognized as endemic regions for HTLV-1.

How Does HTLV-1 Cause ATLL?

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Prôa was born in São José dos Campos, São Paulo State, and earned a degree in molecular sciences from the University of São Paulo (USP). She also trained as a mezzo-soprano singer at the Academy of the São Paulo Symphony Orchestra (OSESP), where she first began combining her love of music and science. 

At Einstein, Prôa has focused on developing solutions for Brazil’s public healthcare system (SUS), especially disease-screening algorithms and models that combine climate and health data to predict how environmental changes impact vulnerable populations. 

In this interview with Science Arena, she discusses her route into international academia, data biases in artificial intelligence (AI), and what science still needs to do to better connect with the general public. 

The first chords 

With experience in mathematics and neuroscience, Prôa joined Einstein Hospital Israelita—while still an undergraduate in molecular sciences at USP—to study dystonia, a neurological condition common among musicians. 

The overlap between disciplines was no accident: from the very start, she sought to explain the brain through mathematical models—she had an almost philosophical drive to translate emotions and perceptions into equations. 

Music was never merely a backdrop in that journey. While studying for her degree in molecular sciences, Prôa was also a professional singer and mezzo-soprano with OSESP. 

While observing an orchestra in Germany, she gained insights that would later become central to her mathematical models.

 It was also at Einstein that she discovered a new direction for her work: understanding the direct impact of scientific research on public health. Working first with neuroimaging and later with AI applied to medical imaging, she realized she could shorten the distance between research and real life. 

“I fell in love with seeing science reach people,” she says. 

Since then, her work has focused on developing solutions for Brazil’s public health system (SUS), including disease-screening algorithms and models that combine climate and health data to predict the impacts of environmental changes on vulnerable populations. 

Going global 

Prôa’s international career was not something she planned since childhood. It emerged, she says, from her active desire to understand the global academic system. 

In 2022, she began a PhD in theoretical neuroscience at Columbia University, New York. After completing her second year—at which point the program automatically grants a master’s degree—she took a one-year leave of absence to pursue a master’s in public health at Harvard. She completed the program in May 2025 and resumed her doctoral studies at Columbia the following semester. 

The decision, seemingly unconventional at first glance, stemmed from a realization Prôa had during her PhD. While working on projects for SUS, she noticed that the results had a more tangible and immediate impact than her original line of research involving mathematical models of the brain. 

The shift was not between fields, but between scales: from the laboratory to the healthcare system. To ensure she could maintain the same technical quality in this new area, she concluded that she needed training in public health and strategic management. Harvard provided exactly that. 

A turning point came in 2021, before she had even started her PhD, when she joined the Próxima Initiative, a Yale University mentoring program for young scientists in the biomedical sciences. 

For a year, Prôa was mentored by a Yale neuroscience PhD student who guided her through the application process, from understanding the international academic system to the emotional challenge of writing a personal statement. 

At Columbia, she found herself as the only student in her class from outside the elite circles of American higher education, which further motivated her to participate in mentoring programs. 

One of the biggest challenges was writing her personal statement, an essay in which candidates have to present themselves confidently. Prôa says she had to overcome what she describes as a “Brazilian culture of humility,” as well as impostor syndrome, both of which made it difficult for her to talk confidently about her accomplishments. 

Her discomfort with self-promotion, which she believes is something cultural rather than individual, eventually became the basis for a separate communication project. 

With over 30,000 Instagram followers, Prôa now advises young researchers interested in studying abroad, sharing what she has learned about international applications, interdisciplinarity, and academic careers.

The initiative took shape during her master’s degree at Harvard, where she worked as a science communicator for the institution. The response has been especially positive among Brazilian students who do not have access to structured support networks. 

Science without a pedestal

When discussing AI—a central theme of her current work—Prôa is careful to avoid blind enthusiasm. For her, the importance of the technology lies less in its technical sophistication and more in what people are using it for. 

In a country marked by inequality, this means ensuring diagnostic algorithms work across different patient populations. 

“When you train a model using data from only one group, it will not work for others,” she explains. She also stresses that academia needs to learn to engage with the general public, to welcome questions and step down from the pedestal that distances knowledge from the public. 

For those just starting out, her advice is straightforward: “Don’t be afraid to ask questions—there are no stupid ones. And perhaps most importantly, recognize that science is neither a solitary nor a linear path. Results alone are not enough. Science involves communication, human relationships, and politics. Having a support network makes a huge difference.”

How to apply to universities abroad 

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In its early years, the group focused on evaluating the quality of services dedicated to psychological distress. Over time, other issues gained prominence, including studies examining the profile of people seeking help through mental health services—young people included.

Kantorski notes that psychological distress in this age group has increased in recent years, particularly during the COVID-19 pandemic. This observation prompted the expansion of research examining the intersection between mental health and youth.

A study published in 2024 analyzed the mental health of 329 female university students during remote learning. Using questionnaires and standardized models to measure levels of distress, Kantorski and her coauthors concluded that 85% of the sample showed some level of depression, 24% had high levels of anxiety, and 25% reported suicidal ideation.

Pandemic worsened psychological distress among young people

The harmful effects of the COVID-19 pandemic on the mental health of young Brazilians are also addressed in a report on mental health produced by Agenda Jovem FIOCRUZ, an initiative of the Oswaldo Cruz Foundation (FIOCRUZ) that runs projects focused on the challenges facing Brazilian youth.

In the report, the authors state that the pandemic increased levels of psychological distress in the Brazilian population as a whole, but that the effects were felt particularly strongly by young people “because this stage of life is marked by intense sociability and circulation.”

The study examined mental health data available through Brazil’s Unified Health System (SUS), focusing on information related to hospitalizations, mortality, and healthcare services provided to people between 15 and 29 years of age across Brazil.

André Sobrinho, coordinator of the initiative, argues that surveys such as this provide insight into the worsening mental health of young Brazilians. 

A central focus of the survey was analyzing young people’s mental health in relation to factors such as gender, race, and region of residence. Considering these aspects led researchers to conclude that mental health problems and the search for specialized support vary depending on young people’s sociodemographic profile.

One example is the difference between men and women: men have a hospitalization rate 57% higher than women, a figure described in the Agenda Jovem FIOCRUZ report as “substantially higher.”

This combination of socioeconomic factors also helps explain the deterioration of mental health among young Brazilians. One of these is the labor market, marked by a high degree of job insecurity and exhausting working hours, says Sobrinho. 

Family responsibilities and difficulties continuing one’s education are other factors that may affect the mental health of young people.

Therapeutic groups show positive results

This is why it is important to listen to young people to understand their circumstances and provide services tailored to their needs, says Kantorski. One example is a paper coauthored by the researcher aimed at discussing the therapeutic outcomes of groups for adolescents at Brazil’s Psychosocial Care Centers (CAPS).

Based on observations conducted in these settings, the authors documented positive outcomes in the psychosocial rehabilitation of adolescents attending CAPS facilities, particularly regarding issues such as sexuality, family conflicts, and drug use.

According to the UFPEL professor, however, research that places young people at the center of discussions surrounding mental health still needs to become more widespread. 

“These health services need to be better prepared for young people. We need to understand their experiences to address their needs,” she says, pointing to the emergence of social media as an important difference between today’s youth and previous generations.

Australia inspires Brazilian care model

The difficulty of providing adequate mental health services is also being felt in other countries. Ian Hickie, a professor of psychiatry at the University of Sydney in Australia, has been studying the issue for years. 

As early as the 1990s, it was already evident to the researcher that there was a gap between centers dedicated to youth mental health in Australia and the delivery of effective, high-quality services for this population.

In 2006, the National Youth Mental Health Foundation, known as Headspace, was established. The Australian service was set up to build centers where primary mental health services—or gateways into the healthcare system—could be offered to young people.

According to the program’s latest official report, released in October last year, one million young people have already accessed some kind of service offered by Headspace.

But Hickie believes the model has shortcomings. “These centers are focused on physical infrastructure. The objective is to establish new clinics that create gateways to increase access to healthcare,” the specialist says.

The effectiveness of Headspace has already been examined in scientific studies. A paper published in 2023 in PLOS One analyzed data from 58,000 young people who accessed the service between 2019 and 2020.

To evaluate patient outcomes, the authors focused on self-reported psychological distress among young people, quality-of-life measures also reported by patients, and assessments made by healthcare professionals after young people accessed Headspace centers. 

The results were positive: approximately one-third of patients showed improvement in psychological distress, while half reported improvements in quality of life.

However, there are also counterarguments regarding the lack of robust evidence supporting the service. In a paper published in 2023 prior to the study featured in PLOS One, other researchers argued that published studies on Headspace lack standardization in measuring service outcomes and that, even when positive outcomes are observed, they are generally not clinically significant.

Hickie also questions the long-term relevance of programs such as Headspace. He argues that models centered on physical clinics are not scalable and are unable to address the full complexity surrounding the deterioration of young people’s mental health. 

Digital tools expand access to care

One possible solution is the adoption of digital tools. “In the digital age, young people can become active participants in monitoring their own mental health so they can access additional support,” Hickie summarizes.

The University of Sydney professor is involved in various projects using digital resources in an attempt to build high-quality mental health services dedicated to young people. One such initiative took place in Brazil through a collaboration with Pedro Pan, a psychiatrist and advisor to the graduate program in psychiatry and medical psychology at the Federal University of São Paulo (UNIFESP).

Pan had previously collaborated with a group of researchers from the University of Melbourne in Australia on a project aimed at identifying early signs of schizophrenia in young people. Years later, the physician again collaborated with Australian scientists—this time with Hickie himself.

The partnership was essential to the development of a Brazilian digital tool designed to assess young people’s mental health based on general patient data. Called Mindcheck and cofounded by Pan, the technology incorporates different aspects such as thoughts, emotions, screen time, and socio-emotional skills to conduct a digital mental health checkup.

According to the psychiatrist, tools such as these may be useful because they generate greater engagement among this age group, since “young people are already using digital media and these kinds of tools.” 

Approximately 100 assessments have already been conducted. Half took place during the platform’s development phase, while the remainder occurred during the pilot stage. “Initial data show that Mindcheck helps identify mental health risk profiles that had often not previously been recognized by young people or their families, while also helping raise awareness of important day-to-day factors such as sleep, screen use, routine, stress, and emotional well-being,” Pan summarizes.

A paper on the development of the platform and qualitative evaluations of its use is currently under review for publication in a scientific journal. In the meantime, individual examples of young people assessed using the technology illustrate Pan’s observations.

One case involved a young woman who was experiencing attention difficulties at school. The initial suspicion was a cognitive disorder, but the Mindcheck assessment suggested that the problem could be related to excessive nighttime screen use. “After reorganizing her sleep routine and reducing nocturnal screen time, there was a substantial improvement in attention and academic performance, without the need for more complex interventions,” says Pan.

International cooperation faces adaptation challenges

The dialogue between Pan and Hickie that resulted in Mindcheck illustrates how international collaborations can play an important role in improving mental healthcare for young people. But these partnerships also have limitations, mainly because of local differences in each region.

One way to improve these adaptations is to establish research standards across different countries, says André Sobrinho of Agenda Jovem FIOCRUZ. Thus, even if studies take local situations of psychological distress among young people into account, international collaboration and exchanges would become easier. 

“It requires a greater effort not only to build exchange networks, but also to establish global scientific and methodological parameters that can serve as a common foundation,” the researcher concludes.

How can research on young people’s mental health be improved?

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A study published in the journal One Earth, conducted by researchers from China, the United States, Germany, the United Kingdom, and Australia, analyzed the volume of stalled construction projects in recent years and estimated the waste associated with these developments. The findings quantify a problem of considerable scale.

What are DALYs?

Materials consumed, benefits unrealized

According to the authors, 485 million tons of materials—such as cement and steel, as well as energy—were consumed in unfinished construction projects, resulting in intensive resource use without a proportional social return.

This process directly contributes to a 9.6% increase in the carbon intensity of the construction sector, which is already recognized as one of the largest global sources of greenhouse gas emissions. 

Health at risk

But the effects are not limited to climate: the study indicates that the waste of materials and energy is associated with deteriorating air quality, a well-established risk factor for cardiovascular and respiratory diseases. The research estimates 2.6 million DALYs (Disability-Adjusted Life Years) linked to pollution generated by stalled construction projects.

The presence of abandoned construction sites in urban areas tends to exacerbate already fragile conditions, contributing to degradation of the built environment, safety concerns, and socioeconomic stress among affected populations. The situation represents approximately US$347 billion (R$ 1.7 trillion) in economic losses. 

How researchers measured the impact

To produce these estimates, the researchers combined data on real estate activity, material consumption and sectoral emissions, considering both the construction lifecycle and the indirect impacts resulting from the interruption of construction work. 

This approach made it possible to assess not only the physical waste, but also its environmental and social consequences over time.

The study argues that China’s real estate crisis reveals a broader structural issue: urban development models disconnected from sustainable planning and economic stability tend to generate significant environmental and social consequences.

Unfinished buildings are no longer merely symbols of economic slowdown—they function as sources of pollution, inefficiency, and risks to public health, highlighting the need to rethink development models in the sector.

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It was in this space between two worlds that Marina Martins Siqueira, a researcher at Einstein Hospital Israelita, built her career. With a degree in business administration from the Federal University of Piauí (UFPI), she did not initially plan to work in public health policy. 

Her path was shaped by an interest in academic research and a drive to understand complex systems.

She was first exposed to health studies during her master’s degree at the Business School of the Federal University of Rio de Janeiro (UFRJ). While working alongside professors who were studying health, Siqueira found a field where research was not limited to theory. 

“When you want to do research without staying confined to theory, the field of health is a great intersection,” she explains.

For her master’s thesis, she chose to study organ donation and transplantation. At first glance it may seem like a narrow topic, but in practice, it is a system that depends on rigorous coordination and defined workflows, dealing with limited resources and complex regulatory decisions. 

There is an element of logistics—her initial study focus—but applied to a complex environment with a direct impact on people’s lives.

Her research combined theoretical reviews, document analysis, interviews, and a quantitative efficiency assessment to understand how the transplant system works and where it could be improved.

To overcome that obstacle, she worked closely with medical colleagues—especially one intensive care physician involved in organ transplants. 

“Having him around was a great help. Although he did not have the academic and theoretical background that I had, he had 100% of the practical, clinical experience,” explains Siqueira.

From a master’s degree to the World Bank: crossing academia and politics

After her master’s degree, Siqueira went straight into a program at UFRJ’s Business School, where she obtained a doctorate of science (DSc) in Business Administration in 2020. Her thesis was on the performance of organ donation and transplant services in Brazil. 

During this period, she spent a year at Duke University, USA, and in her final year, worked as a short-term consultant on projects for the World Bank. The pace was faster, with a focus on answering specific questions about different countries. 

The work still involved reviewing literature and analyzing data and legislation, but with tighter deadlines and more practical objectives.

Siqueira then joined the Institute for Health Policy Studies (IEPS) in São Paulo, where she furthered her studies in systems analysis and engagement with policymakers. 

The experience reinforced a concern she carries to this day: keeping research from becoming too abstract.

Creating CEPPS at Einstein

In 2022, Siqueira joined Einstein Hospital Israelita to help create a center focused on public policy. 

“The idea was to create a think tank, a research center focused on public policy, within Einstein,” she says. “We had to design the center completely—what it would be and what it would do. It was all very new.”

The Center for the Study and Promotion of Health Policies (CEPPS) at Einstein now works both on supporting clinical research and analyzing public data. 

“By supporting and encouraging clinical research at Einstein, we can bring all of our combined academic history together with the empirical knowledge that only specialists, doctors, surgeons—those on the front lines—can offer.”

Results beyond scientific articles

The work of CEPPS is not limited to publishing scientific articles. The center produces different types of content tailored to audience and objective, including institutional reports, analyses for policymakers, and peer-reviewed publications. 

There is also a focus on translating knowledge into more accessible formats and materials.

Three recent research projects illustrate the breadth of the center’s work:

• A study on SUS hospitalizations for congenital infections between 2008 and 2024, published in the journal Antimicrobial Stewardship & Healthcare Epidemiology, identified 194,000 hospital admissions among infants under 12 months, highlighting a significant increase in cases of congenital syphilis, persistent regional inequalities, and gaps in the management of maternal and infant healthcare.
• An analysis of surgical data quality from SUS outpatient and hospital settings, published in Cadernos Gestão Pública e Cidadania (FGV) (“Annals of public policy and citizenship”), showed that in 2023, 76.6% of 20.9 million outpatient surgeries were recorded without an ICD-10 code, indicating data completeness and specificity problems that impact management of the healthcare system.
• A study of mortality in colorectal cancer surgery, published in the ANZ Journal of Surgery in March 2026, analyzed public hospitalizations in São Paulo between 2000 and 2023, finding that age and admission type (emergency vs. elective) are the main predictive factors for death.

Alongside her research, Siqueira has also begun working in education. She is the coordinator of several postgraduate courses and has been an assistant professor for the public policy module of Einstein’s Business degree since 2024.

She also supervises undergraduate research students and strives to maintain a link between theory, data, and institutional practice.

She did not plan her career path in detail. “One thing led to another and I found myself deeply engaged and really enjoying it.”

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Compiled by DATASUS—the Department of Informatics of the Brazilian public health system (SUS), affiliated with the Ministry of Health—these databases support research that analyzes public policies and patterns of care within the SUS. Transforming all this information into sound management decisions, however, is still a challenge.

Created in 1991, DATASUS compiles and standardizes data submitted by states and municipalities. In its 34 years of operation, the department has developed over 440 information systems that directly support federal, state, and municipal public health system management.

In 2023 alone, the system recorded 13 million hospitalizations and 5.7 million surgeries—a snapshot of the scale of care delivery captured each month by DATASUS. 

Death and live birth records exceed 95% coverage nationwide, enabling comparisons between regions. 

“We can integrate all of this in the same system, regardless of whether the baby was born in the public or private system,” explains Alexandre Chiavegatto Filho, professor of Machine Learning in Health at the University of São Paulo (USP) and director of the Laboratory of Big Data and Predictive Analytics in Health (LABDAPS) 

Hospitals, primary care units, outpatient services, and surveillance teams feed into databases such as the Hospital Information System (SIH/SUS), the Outpatient Information System (SIA/SUS), and the Notifiable Disease Information System (SINAN). 

After consolidation and technical validation, the anonymized data are made available on open platforms such as TabNet. “Access is free, which is not the case in most countries,” says Chiavegatto.

From these databases, researchers build indicators, identify regional inequalities, and assess patterns of care. The analysis, however, encounters structural limitations in the system’s own design. 

Although it records events—hospitalizations, procedures, and deaths—DATASUS does not automatically organize this information into clinical pathways. To turn numbers into evidence on care quality or spending efficiency, different databases need to be cross-referenced and data completeness gaps addressed.

Strategic data-use difficulties

One of the main obstacles is fragmentation between databases, which operate in parallel and follow different data entry rules. The gap was identified in a study by the Center for Studies and Promotion of Health Policies (CEPPS) at Einstein Hospital Israelita, published in Cadernos de Gestão Pública e Cidadania (Public Management and Citizenship Journals) in 2025. 

When analyzing recorded surgical activity in the outpatient (SIA) and hospital (SIH) systems, the researchers encountered problems with completeness, trustworthiness, and specificity.

In 2023, 76.6% of outpatient surgeries were recorded without an ICD-10 code—the International Classification of Diseases, which identifies the diagnosis associated with each procedure. 

In the hospital system, 10.6% of surgeries were recorded as multiple procedures, without itemized details. According to the authors, these inconsistencies hinder analyses of care delivery and management and limit the organization of the SUS into care networks. 

This discrepancy prevents the linking of procedures to the condition that led to them. Even in the hospital system, where an ICD code is mandatory, some surgeries are recorded as multiple or sequential procedures, without sufficient detail to identify what was performed. 

For SUS managers, researchers, and auditors, the practical effect is direct: “We have no idea which surgeries were performed on that patient. This makes it difficult to assess whether they were referrals or whether the payment is appropriate,” says Corrêa.

Further challenges

Another limitation is the inability to follow the care pathway of a single patient through the system. It is not possible to know, for example, whether a baby born underweight was hospitalized weeks later, or whether a pregnant woman who attended prenatal consultations experienced complications during labor.

Without this individual timeline, it is more difficult to establish relationships between risk factors, interventions, and clinical outcomes, and to apply predictive models. “The databases are independent from one another, which is a major limitation, including for the use of AI algorithms,” explains Chiavegatto. 

“If we had this type of data, algorithms would be able to learn the characteristics associated with infant mortality and estimate risk probabilities, for example.”

Lack of formal channels hinders the incorporation of evidence into management

Even when data allow the identification of care delivery patterns, translating this evidence into management decisions is not automatic. At CEPPS, for example, an ongoing study is examining gallbladder removal surgeries (cholecystectomy), a highly prevalent procedure within the SUS. 

Although there is well-established evidence that the laparoscopic technique is associated with better outcomes and shorter hospital stays, the data indicate that most are still performed using open surgery.

“DATASUS shows that we are still far from best practices in care delivery, which would be laparoscopic procedures. And this means we are not delivering the best possible outcomes for patients,” says Corrêa, from Einstein. 

“We might be paying less for open surgery because it has a lower cost, but at the same time we are generating costs that we cannot necessarily see.”

The case illustrates another challenge: the lack of well-established institutional channels for incorporating research findings into management. Corrêa notes that there is still no structured methodology for systematically delivering this evidence to decision makers. 

“What has been happening is that the doctors involved in these studies have taken these findings to medical societies and other institutions that discuss public policies in some way, but from a more technical and care delivery standpoint, not a management one,” he says.

Data guide decision-making In emergencies and structuring policies 

Even so, there are situations in which using these databases has become central to administrative decisions. One example was the COVID-19 pandemic, when data on the daily progression of hospitalizations and deaths supported decisions on opening hospital beds, mobility restrictions, and resource allocation. 

Recent regulations have also strengthened the link between funding and care delivery reporting. In December 2025, Ministry of Health (GM/MS) Ordinance no. 9.037 made monitoring the allocation of parliamentary amendment funds for specialized care conditional on recording care delivery in systems such as SIA and SIH. 

In practice, hospitals and services not adequately recording the procedures performed could compromise their funding allocations, making accurate database entry a direct condition for funding.

Well-established indicators, in turn, guide structural policies. According to Chiavegatto, the infant mortality rate is one of the most sensitive indicators in the field of health, because it tends to rapidly reflect disruptions in the system, such as the closure of maternity wards, sanitation failures, or food insecurity. 

“All state health departments primarily use DATASUS data as a decision-making guide,” he says.

In a statement to Science Arena, the Ministry of Health stated that it has been adopting measures to improve and integrate national information systems, such as enhancing the Brazilian National Health Data Network (RNDS) and implementing the SUS Digital program, and that it considers scientific research and monitoring of SUS databases strategic for improving public policies.

The main DATASUS databases

1. SIM — Mortality Information System: records all death certifications in Brazil. Coverage exceeds 95% nationwide. Main source for calculating indicators such as the infant mortality rate.

2. SINASC — Live Birth Information System: records births, with data on pregnancy, childbirth, and newborn health. Coverage also above 95% nationwide.

3. SIH/SUS — Hospital Information System: records hospitalizations in public facilities and those affiliated with the SUS, collecting more than 50 variables per hospitalization—from diagnoses to procedures and length of stay. In 2023, just over 13 million hospitalizations were recorded.

4. SIA/SUS — Outpatient Information System: records procedures performed outside the hospital setting, such as outpatient consultations and surgeries. In operation since 1994.

5. SINAN — Notifiable Disease Information System: records notifiable diseases such as dengue, tuberculosis, and HIV.

6. TabNet: an open access platform that allows users to query all the databases above and tabulate data, without requiring registration or authorization.

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A study conducted by researchers in Austria, Norway, and the Netherlands investigated whether, and to what extent, communicating scientific uncertainties influences risk perception and support for policies related to the impacts of microplastics on human health. The findings, published in January in the journal Public Understanding of Science, indicate that revealing uncertainties or the lack of scientific consensus can slightly reduce risk perception and, consequently, support for regulatory measures by reducing the credibility of the message. The effects, however, are marginal.

How to communicate scientific uncertainties

Methodology: three groups, one fictitious article

A total of 1,126 individuals aged 18 or older, all residents of Austria, participated in the study. They first answered questions about their knowledge and prior perceptions of the topic, as well as their beliefs and attitudes toward science. They were then randomly assigned to three groups: consensus uncertainty, deficit uncertainty, and a control group. 

They all read a fictitious article, in the format of an online newspaper, about microplastics in food and beverages. The text explained what microplastics are, their main sources, and how they enter the food chain, as well as mentioning the benefits of using plastics in the food and beverage sector to provide a balanced perspective.

Next, the researchers presented all participants with a scientific study indicating that microplastics could have negative health effects. The difference was in the framing: the control group received no information about limitations or knowledge gaps; the consensus uncertainty group was informed that there were disagreements within the scientific community regarding the possible impacts; and the deficit uncertainty group received information about existing knowledge gaps and the need for further research.

Results: a small but significant effect

In general, communicating uncertainty led to a slightly lower risk perception in the two experimental groups compared with the control group, but the effect was small. The researchers found no statistically significant differences between the two types of uncertainty when compared directly.

By comparing each condition with the control group, they observed that only consensus uncertainty led to a statistically significant reduction in risk perception. The authors hypothesize that, unlike other types of uncertainty, consensus uncertainty signals that there are experts or evidence that challenge the original claim, which can create room for dissenting or denialist positions.

The role of public beliefs

In addition to the characteristics of the message, the researchers analyzed how public beliefs and attitudes toward science are associated with the effects of communicating uncertainty. They observed that the participants who view science as a process of debate reported higher risk perception, regardless of the type of information they received.

“Our findings indicate that the characteristics of the public influence the effects of communicating uncertainty, but in a more complex and subtle manner than previously assumed,” the researchers note.

In this sense, the authors argue that promoting the view of science as a process of debate and strengthening trust in scientists can help the public deal in a more constructive way with topics marked by uncertainty, but which require preventive actions, as is the case with microplastic pollution.

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The finding is from a cross-sectional study by researchers from the São Paulo School of Nursing and the São Paulo School of Medicine at the Federal University of São Paulo (UNIFESP), published in the Einstein journal in October.

According to the authors, the likelihood of a patient’s successful return-to-work (RTW) outcome varies over time: 

• 67.4% in the first year after a transplant, falling to
• 33.5% ten years later.

The chances of professional reintegration are higher among people with a history of employment prior to transplantation, people with higher socioeconomic status, and recipients of kidney transplants. 

The study evaluated 352 transplant recipients, with an average age of 42, registered with the Brazilian Association of Organ Transplants (ABTx), which compiles national transplant data. The data was collected between July and August 2021, with a minimum requirement of six months since the procedure.

“These findings underscore the urgent need for targeted stigma-reduction strategies, such as public awareness campaigns and workplace accommodations, which can be adapted to diverse cultural and economic contexts,” the authors wrote.

Factors influencing the return to work

The study included individuals from all regions of Brazil, with most from the Southeast (64.1%). The majority were women (56.1%), White (56.5%), and married or in a stable relationship (58.2%).

Kidney transplants were the most common procedure type (62.2%), followed by liver (19.6%), heart (4.5%), bone marrow (4.3%), and other organs. In terms of socioeconomic status, 46.6% were in class C, 33.2% were in class B, 7.7% in class A, and 12.5% in classes D and E.

The analysis identified five factors strongly associated with returning to work: 

• Age
• Race
• Socioeconomic status
• Transplant type
• Previous occupational status 

People aged over 50 were 47% less likely to return to work than those aged 31 to 40. 

Black participants were 64% less likely to return than White participants. People from classes A and B were 2.5 and 2.4 times more likely respectively to resume professional activities than class C individuals, while those from classes D and E were 62% less likely.

Occupational background proved to be a determining factor: people who were unemployed before surgery were 45% less likely to return to work, and those who had never been in formal employment were 87% less likely to reenter the workforce.

“Consistent with the literature, these findings highlight the critical role of socioeconomic factors, including educational level and type of occupation, in determining RTW,” the authors wrote.

Perceived stigma and quality of life

The study also assessed the impact of stigma on quality of life and employment outcomes. The authors defined stigma as the devaluation of individuals based on illness, disability, or race with the potential to affect employment prospects. 

In practice, stigma can manifest as difficulties in securing a position after mentioning the transplant or fear of disclosing a health condition at work.

Stigma was measured using a five-item scale, asking participants if their condition makes them feel different to others, makes others feel uncomfortable around them, makes people avoid them, makes people afraid of them, or impacts their social relationships. Each item was rated on a seven-point scale ranging from “strongly agree” to “strongly disagree,” later rescaled to 0–100.

People who returned to work reported lower perceived stigma than those who remained unemployed, with an average difference of 9.8 points. 

Separated or widowed participants reported higher stigma levels than those who were married or in domestic partnerships, while individuals in classes D and E reported higher stigma than those in classes A and B.

Quality of life was measured using the SF-36 health survey, a validated tool used to assess functional capacity, physical limitations, pain, general health, vitality, social factors, emotional aspects, and mental health. In all areas, transplant recipients scored lower than the general Brazilian population.

The study also identified a statistically significant correlation between stigma and a poorer quality of life. A one-point increase in perceived stigma was associated with reductions in functional capacity (0.24), general health (0.20), vitality (0.25), social functionality (0.37), mental health (0.33), and physical limitations (0.40), as well as a higher perception of pain (0.23).

“The negative effects of stigma on quality of life and returning to work are consistent with those demonstrated by international studies, showing that stigma related to chronic illnesses reduces confidence, self-esteem, and social integration,” the researchers wrote.

Limitations and conclusions

The authors acknowledged some limitations: the cross-sectional design, based on observations taken at a single point in time without following participants over time, does not allow causality to be established; the concentration of participants in the Southeast of Brazil reduces generalizability; and the lack of data on comorbidities, such as cardiovascular diseases and mental illness, which could influence the outcomes. 

Even so, the results reinforce the need for public strategies focused on vocational rehabilitation, reducing stigma, and addressing structural inequalities that hinder full reintegration of transplant recipients into social and economic life.

“Overcoming these structural barriers is essential for optimizing long-term outcomes and ensuring that transplant recipients fully reintegrate into their occupational lives,” the authors wrote.

Public policies aimed at increasing workplace inclusion and tackling stigma could improve the situation, ensuring that the clinical success of transplantation also translates into social and economic quality of life.

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With a degree in architecture and urban planning from the University of São Paulo (USP), Zioni had an interest in the medical field even before her classes began—at one point undecided between studying medicine or architecture.

It was then that her father, an engineer, offered his advice, which was intended for a specific moment but she now recognizes as a broader principle.

“I believe it is very important for us to know what we truly want and not let exams or challenges dictate our path, because there are endless possibilities,” says Zioni, a postgraduate professor at Hospital Israelita Albert Einstein.

During her undergraduate studies, her curiosity was sparked by subjects such as urban planning, design, and art history. But medicine remained an underlying interest.

She took her first step towards reconciling these topics in her final thesis: hospital design.

“I was in the health field right from the start, and it is difficult because it involves a lot of engineering. In the 1990s, people were very reticent and did not want to get involved. They said that no one knew how to design a hospital,” she recalls.

Zioni continued in the field, spending 15 years working on hospital projects and coordination at the American multinational Albert Kahn Associates.

She has designed more than 232,000 square meters (m²) in hospitals, including units at Einstein Hospital. At Kahn, she learned to adapt methods from the automotive industry to the hospital context, such as the organization of production processes.

One of the therapeutic environments designed by Eleonora Zioni, opened in 2009, was the Morumbi unit of Hospital Israelita Albert Einstein in São Paulo. The space was created to make patients, visitors, and employees feel relaxed. A large sculpture of German physicist Albert Einstein (1879–1955) serves as an emotive focal point. The labyrinth outlined on the floor is an invitation to meditate outdoors, a chance for “the brain to shift its focus away from a person’s problems,” says Zioni. The garden provides a space where people can feel in touch with nature despite being in a man-made environment, based on the concept of biophilic design | Images: 1 and 2: Felipe Lampe; 3: Fábio H. Mendes/E6 Images

Quality of hospital environments

When Khan closed its office in Brazil, Zioni chose not to pursue an international career, instead returning to academia, enrolling at USP’s School of Architecture and Urbanism.

Her master’s degree focused on the quality of hospital environments, with an emphasis on intensive care units (ICUs), examining how sensory aspects—noise, smells, ergonomics, light, thermoacoustics, and visual comfort—influence the perception of space.

Her research established connections with environmental psychology, an area that studies how people’s perceptions and feelings are affected by their physical surroundings.

“Hospital architecture is full of rules, health regulations, and a lot of data—that is why people are afraid to get involved. But when you consider the more subjective approach of how a person feels, there is more opportunity to be creative,” says the researcher.

This approach can be applied not only to hospitals, but also to clinics, doctor’s offices, and nursing homes. Seeking greater professional autonomy and the opportunity to link practice with research, she founded Asclépio Consultoria, named after the Greek philosopher Hippocrates Asclepiades (460–370 BC) and the ancient temples where people sought healing and well-being through medicine and contact with the environment.

Today, Zioni is one of Brazil’s most renowned names in hospital architecture. She created and led one of the country’s first postgraduate programs in the field, which was launched at Einstein in 2018 and has already been attended by more than 700 students.

She also edited the book Conhecendo a arquitetura hospitalar (Understanding hospital architecture; Manole Editora, 2022), one of the few up-to-date publications on the subject in Portuguese, with collaboration by renowned international professionals.

Neuroarchitecture: A frontier field

Her current research at Einstein focuses on neuroarchitecture, a field that links neuroscience and architecture to study how environmental stimuli affect human emotions and perceptions.

“When we hear a story, it moves us and leaves a lasting memory. I really like this humanizing aspect,” says Zioni.

“That is why I transitioned from architecture to neuroscience: architecture has always been about listening to people’s needs. I always knew that. But it has been a long road to get academia to appreciate it. I have been working in this field for 30 years.”

In her consultancy work, she analyzes circulation, thermal comfort, lighting, ergonomics, and other factors that directly impact user well-being.

Biophilic design, which aims to bridge the gap between nature and man-made environments, has become another key element of her work. “Sustainability is essential because we spend 90% of our lives in man-made environments and we need to feel at home in them, to bring nature closer.”

Science could contribute even more effectively to finding solutions to society’s problems if researchers were to put more stock in aspects such as creativity, sensitivity, and empathy, Zioni says.

She points out that thinking outside the box is increasingly what sets us apart from technologies like artificial intelligence. “The more creative, sensitive, and humanized we are, the more unique we become.”

Neuroarchitecture, she emphasizes, is one of the most promising fields for the coming decades, with the potential to address various mental health challenges. “Understanding the subjective needs of individuals and translating them into more empathetic environments is an essential step towards creating a better society.”

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