The target culture: origins (1)

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Cochrane and the rise of evidence-based medicine

Only the most paranoid would believe that there are people who deliberately set out to corrupt the nation’s education systems, health service or police force. Even if someone wanted to do this, it would be very hard to plan it and carry it out. But if we go back to the start of the journey, I hope that we will be able to see how in almost imperceptible steps, we moved from an inspired and humanitarian experiment to a profoundly damaging instrument for social manipulation.

It began with a very successful strategy to improve the education of doctors.

Archie Cochrane was born in Scotland in 1909. After gaining a Double First at Cambridge, and volunteering as a doctor in the International Brigade in the Spanish Civil War, (where he got involved with Ernest Hemingway in a bar ("an alcoholic bore") he joined the British army at the start of the second world war.

Cochrane was captured during the fall of Crete in 1941 and he found himself one of 8,000 prisoners of war living in overcrowded converted barracks. They were demoralised and hungry, living on a diet of some 650 calories a day (less than a quarter of the calories that most guidelines suggest that men need). They were given.a mug of ersatz coffee at breakfast, a bowl of soup and two slices of bread in the evening.[1]

It was in this wretched camp that the Germans appointed Cochrane as chief medical officer – in spite of his lack of qualifications: unlike most of his colleagues, Cochrane had some knowledge of medicine. His sick-bay had just three treatments: aspirin, a weak skin disinfectant and a mild defence against diarrhoea.

Sickness was rife in the camp. In August 1941, Cochrane was faced with an epidemic of oedema, the swelling of the legs that used to be called dropsy. The German camp authorities were reluctant to do anything.

Cochrane had a hunch that the cause of the epidemic was diet, and in particular vitamin deficiencies. He hoped that if he could prove this by providing evidence, the authorities would be moved to make changes.

To set this up, Cochrane bribed a guard to buy some yeast on the black-market. He then set up a test with twenty patients in two separate wards. He gave two spoonfuls of yeast to those in one ward and a placebo to those in the other. It was one of the first attempts at a randomised control trial[2]. Although the sample was not very large and could not be supervised very closely, the results were conclusive. After four days, the patients who were taking yeast were measurably better, while those in the control group showed no change. Cochrane wrote up the results carefully and presented the evidence with numbers, graphs and tables to the German officers. The response to this presentation  was dramatic. As Cochrane says, “The next morning, a large amount of yeast arrived; in a few days the rations were increased to provide about 800 calories a day.” By mid September, the epidemic was over. 

It is now considered to have been one of the first modern attempts to use scientific methodology to gather evidence to determine whether a particular clinical approach was effective[3]. Although his methodology was far from perfect, the experience opened Cochrane’s eyes. He recognised that he had stumbled on something that had the potential to transform the basis on which doctors took clinical decisions.

Later in the war, a contrasting experience brought this home. By now he was in a prison camp in Germany, working in a tuberculosis ward alongside medical experts who had completed their training. Cochrane wrote, 

“I knew that 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.”[4]

His colleagues were following the standard practices that all doctors were taught at the time. They did not question whether or not it worked.

When the war was over, Archie Cochrane found that the medical profession in general, and medical education in particular, was still a culture that the British Medical Journal would later call “expert-based medicine”.  By this they meant that experts taught trainee doctors dogmatic ‘facts’, and the trainees were expected to believe them unquestioningly and regurgitate them in their exams.  The character of Sir Lancelot Spratt in the 1954 film "Doctor in the House" caricatures this very well:

All Cochrane's experience made him challenge this. He welcomed the new National Health Service and believed it had a responsibility to be cost effective and efficient. So he continued to explore his idea of collecting data from meticulously run trials, information which other doctors could then use to support their decision-making. 

His work took him to South Wales to a unit concerned with lung disease among miners. He devoted himself for some twenty years to collecting evidence about the levels of coal dust in the pits and how this related to illnesses suffered by the coalminers. Professor Peter Elwood worked with Cochrane and he told the BBC,

“Archie Cochrane took research methods into the community and he used to refer to the general community as his laboratory. And so he got answers to do with very early disease, to do with the predictors of disease, factors that increased the risks of living with a disease, rather than just helping people live with the disease which is the main area of work in clinical practice.”[5]

So successful was this approach, that Cochrane saw no reason why it could not be applied right across medical research. He even began to think of ways it could be used outside medicine. But certainly by the late 1950s and 60s, his work and reputation were making major contributions to a change in culture among doctors. By the late 1960s, fewer graduates in any field were willing to accept expert advice on trust. It was becoming clear that the ways that doctors and surgeons were making decisions – in all good faith – that were often questionable[6], and meanwhile modern organisations were beginning to use computers to collect and collate data. The paradigm was changing.

Cochrane continued to campaign for the medical community to adopt a more scientific methodology. His book  Effectiveness and Efficiency: Random reflections on health services  published in1972 highlighted the lack of reliable evidence behind many healthcare interventions. The methodology he was proposing was eventually defined as,

“Evidence collected from a wide range of sources to help make better decisions, used alongside the expertise of the individual doctor all for the benefit of the individual patient.[7]”

The idea was that doctors could make better decisions as to how best to help their patients by using evidence from many sources, adding to what they had learnt in training, and supplementing their own experience. (This idea was so successful in practice that after Cochrane’s death, former colleagues set up the Cochrane Collaboration, with 10,000 people in more than a dozen centres around the world, who continue to this day to prepare and maintain reviews of randomised trials provide evidence for medical policy making).Evidence-Based Medicine became the established paradigm. It was so successful and became such a buzzword, that there was a tendency to forget that his original aim was for research-based evidence to support doctors’ decision-making by being used alongside their own experience, their knowledge of their patients, and their own common sense.

When the concept was borrowed for evidence based decision-making in other fields, this omission was just as dangerous.

[Next: The problem with problems ]

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[1]Cochrane, Archie L; Blythe, M. One Man’s Medicine: an autobiography of Professor Archie Cochrane BMJ London, 1989

[2]Holme, Chris, Archie Cochrane, father of evidence based medicine The History Company 2013 http://historycompany.co.uk/.

[3]Although The first reported clinical trial was conducted by James Lind in 1747 to identify treatment for scurvy, it was not until 1948 that the first paper on a randomised controlled trial was published in a medical journal.

[4]Cochrane, A. L. (1972).

[5](BBC Wales 2008)

^[6]“Expert opinion, experience, and authoritarian judgment were the foundation for decision making. The use of scientific methodology, as in biomedical research, and statistical analysis, as in epidemiology, were rare in the world of medicine.”  (Sur, Roger L; Dahm, Philipp, History of evidence-based medicine Indian Journal of Urology, 2011 Vol 27 Issue 4)

 ^[7]“the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. ... [It] means integrating individual clinical expertise with the best available external clinical evidence from systematic research." This branch of evidence-based medicine aims to make individual decision making more structured and objective by better reflecting the evidence from research. It requires the application of population-based data to the care of an individual patient,while respecting the fact that practitioners have clinical expertise reflected in effective and efficient diagnosis and thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences. (Sackett, D L; Rosenberg, W M; Gray, J A; Haynes, R B; Richardson, W S, Evidence based medicine: what it is and what it isn't BMJ 1996 Vol 312 issue 7023)