Dr.
Kerr White, the former deputy director for health services at New York’s
Rockefeller Foundation, isn’t likely to forget that talk he gave in 1976 on
evidence-based medicine.
He
was telling his audience that only 15 to 20 percent of doctors’ interventions
had been proven to do more good than harm, when a voice called out in
mid-sentence: “Kerr, you’re a damned liar. You know perfectly well that it
isn’t more than 10 percent!”
Unmistakably,
the voice belonged to Dr. Archie Cochrane — noted British epidemiologist,
pioneer of evidence-based medicine, and a man never afraid to speak his mind.
It
was Archie who famously observed in 1979 that the medical profession lacked a
critical summary of randomized controlled trials (RCT)s. His words led to the
formation of the first Cochrane Centre, launched 10 years ago in Oxford,
England. Today, there are 15 Cochrane Centres around the world which facilitate
the work of an international group of researchers inspired by Archie’s vision.
Archibald
Leman Cochrane was born in 1909 in Scotland. From his autobiography, One
Man’s Medicine, emerges the picture of an independent-minded, eternally
curious person who possessed a quick wit and suffered no fools. (Having met
Ernest Hemmingway, Archie dismissed him as “an alcoholic bore.”) Archie was
also capable of great kindnesses: as a medical officer in a prisoner-of-war
camp, he held a screaming, dying Soviet soldier in his arms to comfort him; and
later, as a medical professor, he discreetly counselled students who broke into
tears due to unwanted pregnancies.
“Archie
had a great desire to stimulate and challenge others. He was a delightful
conversationalist,” recalls Dr. Peter Elwood, a former colleague and friend,
who succeeded Archie as director of the Medical Research Council Epidemiology
Unit in Penarth, Wales.
Sometimes,
that desire backfired. “At meetings he would occasionally attack a clinician,
asking, ‘Why did you not randomize?’” Dr. Elwood says. This often
irritated the speaker rather than stimulating discussion. “Whenever Archie
indicated that he wanted to ask a question, I would duck!”
In those days, the RCT was a new
innovation, Dr. Elwood adds, and “many a clinician did not understand this
research strategy, let alone what the single word ‘randomize’ might mean.”
According
to Bandolier editor Andrew Moore, Archie “could think the unthinkable,
question the unquestionable, and be thoroughly interesting.” Moore has said
that if he had to choose one book to take to a desert island, it would be
Archie’s Effectiveness and Efficiency: Random Reflections on Health
Services. If this seems an unusual choice, it’s a tribute to Archie’s
wit and his call-it-as-you-see-it style.
Effectiveness
and Efficiency, published
in 1972, caused a stir by arguing that the British National Health Service (NHS)
could be vastly improved by using RCTs to test interventions.
One
chapter tells of a crematorium worker who found his job extremely satisfying
because of the way in which “so much went in and so little came out.”
Commented Archie: “I thought of advising him to get a job in the NHS.”
Archie
began his colorful career by studying medicine in London in the 1930s. During
that decade, he underwent psychoanalysis for two years and followed his analyst
from Vienna to Holland. He also volunteered with a field ambulance unit in Spain
during the Spanish Civil War. Along the way, he learned fluent German, Dutch and
Spanish (and later, Russian and Yugoslav).
When
WWII broke out, Archie joined the British Army. Captured in 1941, he spent four
years as a medical officer in several prisoner-of-war camps, where he cared for
worried, sick and hungry men and coped by writing admittedly bad poetry.
To
help weary patients escape work drills, Archie coached them in the fine art of
malingering. Backaches and migraines were his specialty, but he also
stage-managed small epidemics of mumps and acute nephritis. “I used the French
rather than the British as they were better actors,” he says. Later, he
apologized “to any GP who may be treating anyone I trained.”
Archie
treated many prisoners with tuberculosis, but lamented the lack of evidence to
support treatments. “I had considerable freedom of clinical choice of therapy:
my trouble was that I did not know which to use and when...I was afraid that I
shortened the lives of some of my friends by unnecessary intervention.”
After
the war, he studied the epidemiology of tuberculosis in Philadelphia and then
joined the MRC’s Pneumoconiosis Research Unit in Wales.
In
1948 came a milestone in medical history: the first RCT — on streptomycin and
tuberculosis — was published. Fascinated, Archie wondered how other medical
treatments would stand up to the test of an RCT. He also became convinced of the
value of good research data and decided to always aim for response rates of at
least 90 per cent.
During
a typical day in the pneumoconiosis survey, Archie interpreted about 100 chest
x-rays, visited nearly that many homes to persuade people to be x-rayed, took
about 40 industrial histories, and in the evening advised 30 or 40 miners about
their chest x-rays. At night, he drove colleagues home in his trademark green
Jaguar.
In
1960, he became director of the MRC’s epidemiology research unit in Cardiff,
as well as the David Davies professor of tuberculosis and chest diseases at the
Welsh National School of Medicine. Here, he lobbied hard to include epidemiology
and medical statistics in the curriculum.
To
keep in touch with students, Archie hosted dinners at his farmhouse. “We
talked of politics and medicine, sex, and books. My taste in pictures and
sculpture was fiercely criticized...They liked my stories about the Spanish
Civil War and prisoner-of-war camps. In fact, they seemed to enjoy these dinners
almost as much as I did.”
In
1965, Archie’s sister was diagnosed with porphyria, an inherited disease in
which the affected parent has a 50:50 chance of passing it on to a child.
Archie, too, had inherited it.
Since
barbiturates and sulphonamides can provoke acute attacks of porphyria, Archie
encouraged family members to be tested for the condition. He held a sherry party
for Cochrane relatives, gave a little talk about porphyria, and handed out kits
to collect urine and feces samples for testing.
When
the Cochrane side tested negative, Archie mailed a do-it-yourself sample kit
around the world to his mother’s relatives. True to his passion for high
response rates, he eventually examined 152 of 153 living descendants on the
affected side of the family.
Archie
published various papers on porphyria. After presenting one, he concluded by
stating that “My stool is likely to become more famous than my (university)
chair.”
In
1974, Dr. White invited him to lecture at Johns Hopkins University. “He was a
very good speaker, very amusing, with a sort of understated humor,” recalls
Dr. White, who was the prime mover in promoting Efficiency and Effectiveness
in the U.S.
Archie
had surgery for colon cancer in 1983. He spent his last five years at his
farmhouse, where he took great pleasure in his garden. Archie died in 1988.
Archie
Cochrane conducted only one clinical trial, during his WWII years as a prison
doctor. When a number of men developed heavily swollen ankles, Archie diagnosed
a protein deficiency and experimented to find the best treatment.
He
chose 20 men with severe swelling and put 10 in each of two small wards. Those
in one ward received three daily portions of protein-rich yeast, obtained on the
black market. Those in the other ward got one daily vitamin C tablet out of
Archie’s small emergency reserves. By the fourth day, eight out of 10 men in
the yeast room felt better, but no one in the vitamin C room.
“I
wrote it up carefully and took it to the Germans at 1:30 p.m.” In tattered
khaki shorts and shirt, with his emaciated, jaundiced face surrounded by a mass
of red hair and beard, Archie says he must have looked a strange sight.
Archie
says he always felt rather emotional about this trial and ashamed of it. “It
was a poor attempt. I was testing the wrong hypothesis, the numbers were too
small, and they were not randomized. The outcome measure was pitiful and the
trial did not go on long enough. On the other hand, it could be described as my
first, worst, and most successful trial.”