January 3, 2011 ~ Day 25 Bypass The Hype

Photo courtesy of Cardiff University Library
Cochrane Archive, University Hospital Llandough


Effectiveness and Efficiency are probably not the sexiest words that spring to mind at any given moment. That said, when it comes to living well, there is a lot to be said for both.

This is the story of Archie Cochrane, a researcher whose lifelong passion for effectiveness and efficiency just may save your life someday.

By all accounts Archie Cochrane was a pretty fascinating guy. When he was eight, his Scottish father died in the Battle of Gaza. Devoting himself to his studies and demonstrating a special fascination with science, he had by age 23 enrolled in medical school at the University College Hospital in London. Three years later Archie found himself on the battlefields of the Spanish Civil War, serving in the international brigade.

When England entered World War II, Archie became a captain in the Royal Army Medical Corps where he served until being captured by Germany as a prisoner of war in Crete. He remained a POW medical officer in Greece and Germany for four long years until the close of the European conflict in 1944. The experiences he had in German prison camps changed the way he viewed medicine for the rest of his life.

In the first prison camp (Salonika, Greece) where he was interned for six months, Archie was the senior medical officer ~ and for quite a while, the only doctor at all. As he later explained, "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 diarrhea. In addition we had severe epidemics of typhoid, diphtheria, infections, jaundice, and sand-fly fever, with more than 300 cases of 'pitting edema above the knee'. To cope with this we had a ramshackle hospital, some aspirin, some antacid, and some skin antiseptic."

Archie expected that hundreds of the POWs would die from diphtheria since there was no real therapy available, but to his surprise there was only one death during this time that did not result from gunshot wounds.

Knowing full well that it wasn't his own medical skill or special drugs keeping the 20,000 POWs healthy, Archie gained a new respect for the healing power within each individual. "It demonstrated ... very clearly the relative unimportance of therapy in comparison with the recuperative power of the human body."

Later transferred to Elsterhost, a camp where POWs with tuberculosis were grouped together behind barbed wire, Archie faced the awful task of caring for his dying comrades without much hope of healing them. While there was sufficient food and he could give his patients bed rest, 'pneumothorax and pneumoperitoneum', over time he ended up not only attending their funerals but also having to act as a priest. "I got quite expert in the Hindu, Moslem, and Greek Orthodox (burial) rites," he remembered.

During this time he read a German propaganda pamphlet promoting clinical freedom and democracy, and had trouble getting his head around it. Archie felt that his problem was not lack of freedom to decide how to treat his patients. The problem was simple - he did not know which medications to use and when. "I would gladly have sacrificed my freedom for a little knowledge."

He knew that there was no proven evidence to show that any of the current treatments for tuberculosis were actually effective, and he harbored the real fear that he had "shortened the lives of some of my friends by unnecessary intervention."

Once freed from the camps, Archie devoted the rest of his life to learning and teaching about tuberculosis and acting as Director Medical Research Council Epidemiology Research Unit in Cardiff, Wales. He wanted to give doctors real, concrete data to base their decisions on... so he decided to study the health of populations and communities (not just individuals) and to follow up those studies for ten, twenty, thirty years.

With the publication of his masterwork in 1972, Archie argued persuasively that it was crucial for doctors to base their clinical decisions on evidence from randomized, controlled trials. These ideas made a lot of sense, and Archie developed an international following.

Archie Cochrane believed that to keep medical care relevant, all randomized controlled trials needed to be cataloged in a database according to specialty and analyzed periodically to see what the data actually said. For example, if data from multiple trials proved that giving a corticosteroid shot could actually save a huge percentage of premature babies from protracted sickness and death, doctors should have access to that information in order to give the best clinical advice.

He challenged physicians and governments to figure this out, which led a UK-based international group led by Sir Iain Chalmers to create the Oxford Database of Perinatal Trials where systematic reviews were made of the care given to mothers and babies during pregnancy and childbirth. Archie was thrilled, calling this "a real milestone", but he was not yet satisfied.

Before his death in 1988, Archie threw down one final gauntlet: that independent groups should make a practice of reviewing the data for all fields of medicine, beyond perinatology.

This led to the creation, five years after his death, of the first Cochrane Center... and then the founding in 1993 of the Cochrane Collection.

The Cochrane Collection is an independent non-profit organization funded by governments, universities, hospital trusts, charities and personal donations. By design, they will NOT accept funding from commercial sources or any organization whose goals might be in conflict with the Cochrane goal of producing honest, unbiased reports.

The goal of this organization is simple - to provide sound evidence from which healthcare providers, policy makers, patients, caretakers and patient advocates can draw upon to make important decisions.

Since its founding eighteen years ago, the Cochrane Collaboration has involved over 27,000 volunteers worldwide and has now submitted over 4,000 Cochrane Reviews available online in the Cochrane Library.

The reviews themselves attempt to answer specific questions that are commonly encountered by healthcare providers and patients, for example, "Does Vitamin C actually help to cure a head cold?", "Can antibiotics help alleviate the symptoms of a sore throat?" or "Does cranberry actually prevent urinary tract infection?"

Volunteers then search for all existing primary research on each topic, organize it, and assess the full set of data using extremely strict guidelines to figure out whether or not there is conclusive evidence about a particular treatment.

My husband and I have found that once you get started looking through these reviews, they are sort of addictive to read. They are also very freeing.

In 2009 before learning about Cochrane reviews, I fell prey to the media hype about H1N1 and the dire need to get vaccinated in order to help protect our children... especially infants. As the mother of a premature baby I felt enormous pressure to get my vaccination, even though I have always been leery about flu shots in the past.

Long story short, I got the shot and had a terribly debilitating, immediate reaction that set off a cascade of autoimmune problems from which I am still recovering. Multiple doctors have now told me that I may never have another flu shot again in my life.

Imagine my chagrin, then, to discover that the Cochrane Collection has answered the question "Are influenza vaccines useful for healthy people?" After systematically assessing 50 different trials involving over 70,000 people, this was their conclusion:

"Influenza vaccines have a modest effect in reducing influenza symptoms and working days lost. There is no evidence that they affect complications, such as pneumonia, or transmission."

Worse still, the Review warned that studies funded by the pharmaceutical industry were far more likely to have been published in famous journals and that publicly funded studies were far less likely to report positive conclusions about the vaccines. "Reliable evidence on influenza vaccines is thin but there is evidence of widespread manipulation of conclusions and spurious notoriety of the studies."

So there you have it. I made an important healthcare decision based on scary headlines in the local paper, rather than consulting the real data which said that getting a flu shot wasn't going to stop me from giving my kid the flu or ending up in the hospital. Ugh!

As a mother making decisions all of the time about what kind of food to feed my kids, what types of medicine to accept for them when they are ill, whether to vaccinate, etc. I am so grateful to have a reliable source of information that can help me make the best possible choices. The message in today's column is pretty straightforward: Ignore the media hype... ("RARE PANDA FLU KILLS 10!!!") and find the real answers for yourself by consulting a Cochrane Review. It's like the Rotten Tomatoes for healthcare options. You'll never waste your money or time on a treatment that's only 19% fresh again.