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  • br As outlined in in

    2019-04-15


    As outlined in in October, 2016, my vision for WHO can be summed up in five words: equity, rights, responsiveness, evidence, and partnership. In this NVP-BKM120 cost context, I am pleased to respond to the authors of the open letter in , on the leadership role that WHO must play in tackling the high prices of health technologies and lagging innovation that impede people\'s access to quality health care.
    First I would like to thank the authors of the open letter published in that highlights one of the key priorities that WHO should address in the coming years: affordable medicines and innovation against commercially unattractive diseases.
    I have received several letters inviting me to express my views on specific issues in global health, including the open letter published in . My general position is that as Director-General, I will operate at all times within the context of decisions made by the WHO\'s Member States in the Governing Bodies. In preparing myself for serving as WHO Director-General, I anticipate my future responsibilities in a way that reflects the priorities that I have set out in the vision statement that I have submitted to the WHO.
    I would like to thank the authors for raising the critical issue of access to medicines and to approach the specific proposal for a research and development (R&D) convention in that broader context.
    In response to the open letter on patient-centred research and development (R&D), failures and imbalances that characterise the global pharmaceutical market have long been recognised and dealt with, although no breakthrough has been reached in finding real solutions to these problems. While accessibility and affordability challenges in lower income countries still persist and call for reinforced actions, developments of recent years have brought about or revealed further unfavourable phenomena, such as extremely high, unaffordable prices, sometimes limited therapeutic advances brought about by innovative drugs or in certain cases lack of real innovation. These already represent global challenges in times when the socioeconomic relevance and importance of health and the health sector is being recognised and reflected in the Sustainable Development Goals, foreseeing to ensure global access to medicines and vaccines.
    I thank Peter Winch and Elizabeth Thomas for their thoughtful letter concerning our trial in and for highlighting the profound challenges associated with changing multiple behaviours in public health interventions. To improve the effectiveness of public health strategies, we need more innovative behaviour change interventions that undergo rigorous evaluation and more debate about what works, what doesn\'t, and why. It is thus vital that reports of trial outcomes be accompanied by detailed exploration of the reasons for the outcomes in the study context. Winch and Thomas rightly point out the difficulty of interpreting trial findings testing complex interventions in the absence of data on fidelity and other key process indicators. As mentioned in the discussion of our paper and prespecified in the objectives published in the , we integrated a full process evaluation into our study protocol. This measured seven domains (fidelity, dose delivered, reach, recruitment, participant engagement and responses, acceptability, and context), guided by Steckler and Linnan\'s framework and the Theory of Change approach. Due to the convention of separating reports of process and outcome evaluations, the results are the subject of a second manuscript that will be published in due course. This subsequent report will engage in detail with the important questions raised by Winch and Thomas.
    David P Thomas and Marita Hefler suggest ways to reduce adolescent smoking in low-income and middle-income countries, in response to the Article by Bo Xi and colleagues (November, 2016). We suggest some additional measures to reduce adolescent smoking in India.
    Historically, most of the smoked tobacco in India has been in the form of bidis, because they are cheap and locally manufactured. Evidence suggests that tobacco use rates are increasing in India, with a clear shift in consumption away from bidis to cigarettes among adults, particularly young adults aged 15–29 years. However, there is no such evidence for a consumption shift in adolescents aged 13–15 years despite high bidi smoking rates in this population. We appreciate Mrinal Barua and colleagues\' interest in our paper, and for proposing social class-specific strategies to reduce adolescent smoking in India. The existence of a social gradient in tobacco use has been clearly established in people with lower socioeconomic status, and megakarocytes is also pronounced in Indian adults. To our knowledge, no evidence of this pattern exists in Indian adolescents and future studies are therefore warranted.