WHO WAS ARCHIE COCHRANE? WHY DOES HE MATTER?

Wednesday, 18th of May 2011

In 1979 [Cochrane] wrote, "It is surely a great criticism of our profession that we have not organised a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomised controlled trials."

Archie Cochrane: the name behind The Cochrane Collaboration

The Cochrane Collaboration is named in honour of Archie Cochrane, a British medical researcher who contributed greatly to the development of epidemiology as a science.

Professor Archibald Leman Cochrane, CBE FRCP FFCM, (1909 - 1988)

The photograph may be reproduced without permission. However, please acknowledge its source: “Cardiff University Library, Cochrane Archive, University Hospital Llandough”.

Background of The Cochrane Collaboration

Archie Cochrane is best known for his influential book, Effectiveness and Efficiency: Random Reflections on Health Services published in 1972 [1]. The principles he set out in it so clearly were straightforward: he suggested that, because resources would always be limited, they should be used to provide equitably those forms of health care which had been shown in properly designed evaluations to be effective. In particular, he stressed the importance of using evidence from randomised controlled trials (RCT's) because these were likely to provide much more reliable information than other sources of evidence. Cochrane's simple propositions were soon widely recognised as seminally important - by lay people as well as by health professionals.

In 1979 he wrote, "It is surely a great criticism of our profession that we have not organised a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomised controlled trials."[2] His challenge led to the establishment during the 1980s of an international collaboration to develop the Oxford Database of Perinatal Trials.

In 1987, the year before Cochrane died, he referred to a systematic review of randomised controlled trials (RCT's) of care during pregnancy and childbirth as "a real milestone in the history of randomised trials and in the evaluation of care", and suggested that other specialties should copy the methods used [3]. His encouragement, and the endorsement of his views by others, led to the opening of the first Cochrane centre (in Oxford, UK) in 1992 and the founding of The Cochrane Collaboration in 1993.

Works by and about Archie Cochrane

Cochrane AL. Effectiveness and Efficiency. Random Reflections on Health Services. London: Nuffield Provincial Hospitals Trust, 1972. (Reprinted in 1989 in association with the BMJ, Reprinted in 1999 for Nuffield Trust by the Royal Society of Medicine Press, London (ISBN 1-85315-394-X) .) [1]

Cochrane AL. 1931-1971: a critical review, with particular reference to the medical profession. In: Medicines for the year 2000. London: Office of Health Economics, 1979, 1-11. [2]

Cochrane AL. Foreword. In: Chalmers I, Enkin M, Keirse MJNC, eds. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989. [3]

Dickersin K and Manheimer E. The Cochrane Collaboration: Evaluation of health care and services using systematic reviews of the results of randomised controlled trials. Clinical Obstetrics and Gynecology 41(2):315-331, 1998. Provides an excellent account of how Archie Cochrane's vision inspired others, leading ultimately to the founding of The Cochrane Collaboration.

Archie Cochrane: Back to the front, edited by F. Xavier Bosch, uses Archie Cochrane's experiences in the Spanish civil war as a starting point to discuss his life and work, and his influence on the founding and development of The Cochrane Collaboration. Includes commentary from a diverse group of family, friends and colleagues. Copies of the book are available for €75.00 (GBP £52.00); to order, use this order form.

One Man's Medicine, Cochrane AL (with M Blythe). London: BMJ (Memoir Club), 1989. The definitive autobiography of Archie Cochrane.

**Special note**
To celebrate the centenary of Archie Cochrane's birth, Cardiff University is publishing:
One Man's Medicine. An autobiography of Professor Archie Cochrane, by A L Cochrane and Max Blythe in a 2009 paperback edition, ISBN No: 978-0-9540884-3-9, priced £14.99.

To order online: www.cardiff.ac.uk/cochrane or by post contact: "One Man's Medicine" Sir Herbert Duthie Library, Cardiff University, B2, University Hospital of Wales, Cardiff CF14 4XN, UK.

Excerpts from Archie Cochrane's publications

Excerpts from Cochrane's book, Effectiveness and Efficiency: Random Reflections on Health Services, a critique of Britain's National Health Service.

"I lack some of the qualifications required to write a book of this kind. The most serious of these is, I imagine, the paucity of my experience of patient care and the atypical nature of the little I have had. Nearly all of it was during my four years as a prisoner of war in German hands which educated me in two very different ways. The first experience was in the Dulag at Salonika where I spent six months. I was usually the senior medical officer and for a considerable time the only officer and the only doctor. (It was bad enough being a POW, but having me as your doctor was a bit too much.) There were about 20,000 POWs in the camp, of whom a quarter were British. The diet was about 600 calories a day and we all had diarrhoea. In addition we had severe epidemics of typhoid, diphtheria, infections, jaundice, and sand-fly fever, with more than 300 cases of 'pitting oedema above the knee'. To cope with this we had a ramshackle hospital, some aspirin, some antacid, and some skin antiseptic.

The only real asset were some devoted orderlies, mainly from the Friends' Field Ambulance Unit. Under the best conditions one would have expected an appreciable mortality; there in the Dulag I expected hundreds to die of diphtheria alone in the absence of specific therapy. In point of fact there were only four deaths, of which three were due to gunshot wounds inflicted by the Germans. This excellent result had, of course, nothing to do with the therapy they received or my clinical skill. It demonstrated, on the other hand, very clearly the relative unimportance of therapy in comparison with the recuperative power of the human body. On one occasion, when I was the only doctor there, I asked the German Stabsarzt for more doctors to help me cope with these fantastic problems. He replied: 'Nein! Aerzte sind ueberfluessig.' ('No! Doctors are superfluous.') I was furious and even wrote a poem about it; later I wondered if he was wise or cruel; he was certainly right."

* * * * * * * *

"The second experience in POW life was very different. It was at Elsterhost where all the POWs with tuberculosis (most of whom were far advanced) of all nationalities, were herded together behind the wire. Conditions were in many ways not too bad. Through Red Cross parcels we had sufficient food; we were able to 'screen' patients and do sputum 'smears' but radiographs were very limited. We could give our patients bed rest, pneumothorax, and pneumoperitoneum. There was a French physiologist who was expert in 'adhesion-section', and thoracoplasty was a possibility. We knew our patients almost too intimately. We spent most of the day with them and at night were locked in the same building. We had to attend their funerals and I usually acted as priest. (I got quite expert in the Hindu, Moslem, and Greek Orthodox rites.)

I remember at that time reading one of those propaganda pamphlets, considered suitable for POW medical officers about 'clinical freedom and democracy'. I found it impossible to understand. I had considerable freedom of clinical choice of therapy: my trouble was that I did not know which to use and when. I would gladly have sacrificed my freedom for a little knowledge. I had never heard then of 'randomised controlled trials', but I knew there was no real evidence that anything we had to offer had any effect on tuberculosis, and I was afraid that I shortened the lives of some of my friends by unnecessary intervention."

* * * * * * * *

(This excerpt is from a section dealing with work days lost due to certified illness.)

"There is no doubt that 'certified time lost' is increasing even when standardized for age and that this is a real output of the NHS as it is 'time off' certified by doctors under contract to the NHS.
I hasten to make it clear that I do not think that my colleagues are entirely to blame for all this increase. They have my sympathy, in particular because I was once on the other side. For some time I was the only POW medical officer to a punishment area near Wittenburg. Everyone was supposed to work particularly hard and discipline was very strict indeed, both for us and the Germans. The German MO knew that if he were caught allowing any malingering he would be sent to the Eastern Front. In spite of this I found it perfectly possible to quadruple the number of people 'off sick' at the sick parade. The POWs were carefully trained, and I specialized in the headache-migraine syndrome and back-ache. I used the French rather than the British as they were better actors. I also stage-managed small epidemics of mumps and acute nephritis. No one was ever shot or punished as a malingerer. I do, therefore, realize how difficult it is for my colleagues in general practice, as I note that the two groups of diseases showing the biggest rise are the two areas on which I specialized: 'headache' and 'sprains and strains'. I apologize to any GP who may be treating anyone I trained."

* * * * * * * *

This excerpt is from Cochrane's autobiography, One Man's Medicine. [Cochrane AL (with M Blythe). London: BMJ (Memoir Club), 1989, p 82.]

"Another event at Elsterhorst had a marked effect on me. The Germans dumped a young Soviet prisoner in my ward late one night. The ward was full, so I put him in my room as he was moribund and screaming and I did not want to wake the ward. I examined him. He had obvious gross bilateral cavitation and a severe pleural rub. I thought the latter was the cause of the pain and the screaming. I had no morphia, just aspirin, which had no effect.

I felt desperate. I knew very little Russian then and there was no one in the ward who did. I finally instinctively sat down on the bed and took him in my arms, and the screaming stopped almost at once. He died peacefully in my arms a few hours later. It was not the pleurisy that caused the screaming but loneliness. It was a wonderful education about the care of the dying. I was ashamed of my misdiagnosis and kept the story secret."