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The Cochrane Afraid to Challenge the Diagnostic Acu- Men Ofhis Ancestors Or Peers place or at the wrong time. He was not The Cochrane afraid to challenge the diagnostic acu- men ofhis ancestors or peers. He Collaboration believed that clinical questions often were answered on the basis oftests, Lessons for Public Health rather than on common sense. Practice and Evaluation? Obstetrics offered Cochrane an example ofthe practices ofthe day. Like many other fields ofmedicine, MIRUAM ORLEANS, PHD obstetrics adhered to treatments that perhaps were oftraditional or emo- tional value but which had little basis Archie Cochrane undoubtedly in science. The therapeutic use ofiron wanted to reach providers of and vitamins, the basis for extended health care with his ideas, but he lengths ofstay in hospitals following probably never thought that he would childbirth, and the basis for deciding father a revolution in the evaluation of how many maternity beds were needed medical practices. in Britain were all questioned by In his book ofonly 92 pages, Cochrane, who believed that these "Effectiveness and Efficiency: Random matters could and should be investi- Reflections on Health Services," pub- gated in trials. lished by the Nuffield Provincial Hos- Although Cochrane was by no pitals Trust in 1972, he cast a critical means the first clinician-epidemiologist eye on health care delivery, on many to suggest that randomized controlled A. L Cochrane well-respected and broadly applied trials were an appropriate means of interventions, and on whole fields of deciding questions regarding the effi- were appropriate for laboratory studies medicine and their underlying belief ciency and benefit oftreatment, I can and probably some animal and behav- systems (1). His judgments were think ofno voice that was as strong or iorist psychological experiments. I had founded on his training in science at as filled with common sense as his. taught research methods for many Cambridge University, his experiences I first encountered him in 1970 years and was fully armed with reasons as a physician, as a director ofa Med- when I was invited by Professor Walter as to why RCTs would not work in ical Research Council Epidemiology Holland to spend a post-doctoral year studies ofdirect patient care or of Unit in Wales, and on his observations at St. Thomas' Hospital Medical community interventions. ofmedical care, made while serving as School in London. As a guest faculty I began to think differently about a medical officer in German prisoner member, I was induded in the annual the uses ofRCTs in England, and ofwar camps during World War II (2). trek ofthe (then) Department ofSocial later, in Denver, I became an RCT Cochrane's book clearly expressed Medicine and Clinical Epidemiology practitioner, advocating its use in situ- his commitment to equity in the pro- to the Social Medicine meetings. ations in which RCTs are needed. I vision ofhealth care, his support for In Aberdeen, Scotland, listening to remember that the first and probably the National Health Service and his a presentation-a report ofa health the most influential suggestion came humanism. In this briefvolume, he care survey whose content I no longer from Archie Cochrane. I was not his expressed concern not only with poor remember-I heard a question from only student. quality ofgovernment and practitioner the rear ofthe meeting room, "Well, By the mid-70s, his small book reasoning about health care strategies what about a randomized controlled had been published in seven lan- but with the lack ofevidence support- trial?" The voice was loud, clear and guages. That pleased him greatly, but ing a great many medical practices. intrusive. I asked a colleague for the he remained convinced for many years Above all, he wanted health ser- name ofthe person who felt so free to that although he attracted many vices to be helpful to those served. He interrupt the speaker. "Oh, that's admirers, few were followers. In 1978, found maternity care, hypertension, Archie Cochrane, from Cardiff; he during a visit with him at Rhoose "exuberant surgery," the treatment of says that at most ofthese meetings." Farm, in South Wales, he expressed tuberculosis, and heart disease often Along with many others, I thought disappointment that his views of lacking in logic, delivered in the wrong randomized controlled trials (RCTs) experiments were not more widely September/October 1995 * Volume 110 Public Health Reports 63 3 .. ;:.-.:.:- : : held. He believed not only in the Collaboration extends to Auckland, delivery ofa public health program is experimental method but also that the Milan, Oxford, Leeds, Ottawa, often given as the reason for not doing aggregation ofthe results ofexperi- Copenhagen, Amsterdam, and beyond one. However, a trial is far less expensive ments, followed by critical summaries, to Mexico and Chile. There are now than the delivery ofa program of would be useful to health professionals Cochrane Centers in the United unsubstantiated value or one that may in their medical decision-making. States as well, in Baltimore, San Anto- in fact be unnecessary or harmfiul. Today he has a great many follow- nio, and San Francisco. We also often hear that it is not ers. In November 1992, the opening of The centers coordinate the con- ethical to withhold a "treatment" or a the first Cochrane Centre in Oxford, duct of"systematic reviews" ofthe program from the deserving public. England, was attended by medical published and unpublished literature Iain Chalmers has addressed this scholars, friends from many countries, in medical care. This term "systematic argument, pointing out that what is Cochrane's students, government rep- review" has taken on a more precise being withheld has often itself not resentatives, and a large number of meaning than in the past, referring to been shown to be effective. Advocates well wishers. The day's program stated formally and consistently applied cri- for programs often cannot demon- the centre's philosophy and agenda, teria with which research reports are strate the effectiveness or the effi- honoring Cochrane's main thesis: "that assessed. An article by Cynthia Mul- ciency ofthe favored strategy any limited resources should be used to row (4), evaluating the quality ofmed- more than they can demonstrate that provide forms ofhealth care that have ical review articles, has been ofbenefit the one being replaced did not work. been shown to be effective by properly in standardizing the criteria used in We need the trials; we also need sum- controlled research." reviews. Both published and unpub- maries and systematic reviews so that It is fitting that the Director ofthe lished RCTs provide the raw data for we are as well-informed as is possible first Cochrane Centre is Dr. Iain systematic reviews. before we introduce large scale public Chalmers, a student who became Collaborative Review Groups health programs. Cochrane's lifelong friend. Chalmers (CRGs) produce the systematic At least that is what I think Archie had heard and accepted Cochrane's reviews, assisted by disciplinary spe- Cochrane would say. "challenge to obstetrics." As the first cialists, called "the Fields," who assure director ofthe National Perinatal Epi- that particular areas, for example, mus- Dr. Orleans is Professor Emerita, demiology Unit in Oxford in 1978, culoskeletal and soft tissue diseases, Department of Preventive Medicine Iain Chalmers gathered a capable mul- stroke, pregnancy complications, men- and Biometrics, University of tidisciplinary professional staff, who tal illness, and a great many other Colorado School ofMedicine, developed and provided technical sup- problems are appropriately and well Denver, CO 80262; tel. 303-270- port for the conduct of RCTs in peri- covered. Public health professionals 7839; FAX 303-321-1726. natal health care (3). This unit created (not only those who are health service the Oxford Database ofPerinatal Tri- researchers) have a great deal to learn Tearsheet requests to Dr. Orleans. als that today serves as a prototype for from this particular "medical model." the development ofcomparable data There are few randomized con- References bases in other fields ofmedicine. trolled trials in the fields ofenviron- 1. Cochrane, A. L.: Effectiveness and effi- ciency: random reflections on health ser- This data base, along with elec- mental or occupational health, fewer vices. Nuffield Provincial Hospitals Trust, tronically published reviews, articles in still evaluating the benefits ofschool Oxford, England, 1972. peer reviewed journals, an extraordi- health or health promotion programs. 2. Cochrane, A. L., and Blythe, M.: One nary two-volume review ofperinatal In Denver, a new, centralized and mans medicine: an autobiography ofpro- practices, and a similar review of costly emissions inspection program fessor Archie Cochrane. BMJ, London, 1989. neonatal care has systematically pro- replaced a dispersed inexpensive sys- 3. Chalmers, I.: The work ofthe National vided answers to a wide range ofperi- tem. We do not know that the old sys- Perinatal Epidemiology Unit, one example natal questions. tem did not work. We do not know oftechnology assessment in perinatal care. The notion ofa data base oftrials, that the new system will work. We do IntJ Technol Assess Health Care 7: along with summaries oftheir findings not know clearly what we mean by 430-458 (1991). 4. Mulrow, C. D.: The medical review article: has spread into a dozen fields ofmedi- "work." What were and will be the state ofthe science. Ann Intern Med 106: cine. A worldwide collaborative effort expected benefits to health? 485-488 (1987). is under way to prepare, maintain, and Although vaccines have been sub- disseminate systematic reviews ofthe jected to trials, methods ofdelivery have effects ofhealth care. The Cochrane not. The high cost ofan RCT ofthe 634 Public Health Reports September/October 1995 * Volume 1 10.
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