Random reflections on the Cochrane half centenary

Fifty years ago this Sunday (20 March 1972), Archie Cochrane delivered his seminal lecture “Effectiveness and Efficiency: Random Reflections on Health Services” in the Biochemistry Lecture Theatre of the Edinburgh University Medical School. His book, of the same title, was published by the Nuffield Provincial Hospitals Trust to widespread acclaim. Professor Cochrane had been appointed as the 1971 Rock Carling Fellow by the Trust, attracting a stipend of £1,000 in return for a 20,000-word monograph and lecture on a topic of his choice.

It nearly didn’t happen. The Nuffield Trust’s archives contain a plaintive letter from Cochrane to Gordon McLachlan, the Trust’s Secretary, written in August 1971 and offering to resign his fellowship as he had made so little progress on the draft of his book. He cites numerous pressures – “everything has gone wrong this summer”. The loss of key staff, the burden of running courses in both London and Cardiff on health service changes, involvement in the Faculty of Community Medicine, and the serious illness of three close friends.

He goes on to say that “another unfortunate interruption has been a prolonged quarrel with Mrs Thatcher of the D.E.S. Someone during a local survey wrote to his MP and, although the MP has withdrawn his criticism of my survey worker, she has taken the matter up in a big way in relation to privacy. What she is asking would really wreck all epidemiological work in future, and I have found it necessary to fight it inch by inch. I think I am convincing her Ladyship but it has been a very long, drawn-out battle.”

The wise and pragmatic McLachlan reassured him that resignation was not necessary. “I know very well how involved things can get sometimes, especially with writing. If it is not possible to do the monograph by the end of this year, it will just have to wait off until next.”

The monograph was duly completed, and the lecture given, followed by a reception and finger buffet for 120 guests at 70 pence per head, which included chicken and mushroom vol-au-vents and smoked salmon coronets. The occasion was deemed a great success. More importantly, the monograph went on to be cited as a significant moment in the development of evidence-based medicine. To this day, every biography or journal article on Cochrane’s legacy cites this publication as key.

In a review for the Sunday Times at the time of publication, its distinguished science correspondent, Bryan Silcock, described Cochrane’s monograph as “highly original and challenging. With example after example, the author, Dr A L Cochrane, shows how much of what passes for scientific medicine is at best of unproven effectiveness, at worst actually harmful, and how ineffectiveness is often compounded with inefficiency.”

“In general,” Cochrane himself wrote, “I am emotionally biased in favour of the idea of a national health service. I have travelled very widely and believe our NHS to be the best of a very poor lot, but I view the NHS now as one would a favourite child who is showing marked delinquent tendencies.”

At the time of publication, Archie Cochrane was well established as a pioneer of epidemiology and a champion of randomised controlled trials. He was Director of the newly established Medical Research Council Epidemiology Unit in Cardiff, and had been awarded a CBE for services to medicine.

Cochrane believed that “all effective treatment must be free”. His vision for improving effectiveness lives on through the Cochrane Collaboration, now the Cochrane, established five years after his death.

His autobiography, One Man’s Medicine, illuminates why he felt treatment should be free.

Written with Max Blythe, it is a real page-turner, chronicling his early interest in psychoanalysis; his involvement in a field ambulance unit during the Spanish Civil War; and his experiences as a prisoner of war, first in Crete and then in Germany, where he worked tirelessly and courageously as the camp doctor to care for fellow prisoners. While himself severely incapacitated by hepatitis, he conducted his first randomised control trial to establish whether yeast or vitamin C supplements might improve the condition of emaciated patients with oedema and succeeded in securing yeast supplements for his fellow prisoners. He was awarded a military MBE for his “gallant and distinguished” behaviour in the camps.

Between 1949 and 1959, he pioneered the Rhondda Fach Scheme, a survey of lung diseases in the population of two coal mine areas in South Wales. Writing on Cochrane’s legacy in 2011, J Gerris says that the amount of energy and effort this took “defies imagination. The man was always at work, from early morning to late at night. The individual follow-up and the mass screening sessions he organised – driven by his social feeling and human involvement with the health of tens of thousands of men and their families – stand as an example for excellent clinical epidemiological research.”

Fiona Johnson is a Visiting Fellow at the Nuffield Trust.

This weekend marks 50 years since Archie Cochrane delivered his lecture on “Effectiveness and Efficiency: Random Reflections on Health Services”.