A short biography of Archie Cochrane (1909 - 1988)
Archibald Leman Cochrane was born in Galashiels, Scotland, on 12th January 1909. He became a student at Uppingham School followed by King's College, Cambridge (1927-30). After obtaining a 1st class honours degree he became a research student working on tissue culture studies. He left for Germany and studied psychoanalysis under the guidance of Theodor Reik (while at the same time receiving psychoanalytic treatment from him) who was one of the first students of Sigmund Freud. After starting his medical studies, Cochrane decided to return to London after becoming convinced that his psychoanalytic treatment lacked a scientific basis. Later in his life, Cochrane condemned the entire field of psychiatry for “using a large number of therapies whose effectiveness has not been proven” and for being “basically inefficient.”
Archie Cochrane qualified as a doctor in 1938 and during the Spanish civil war volunteered his services to the Spanish Medical Aid Committee. The next twenty years were the formative ones in his life. During the Second World War he was a Captain in the Royal Army Medical Corps. He was captured in June 1941 in Crete. Cochrane had picked up some German during his time with Theodor Reik and as a result of his linguistic abilities; he was assigned the dual role of a medical officer for the POWs and a negotiator. To his credit, Cochrane remained vigilant about helping the other prisoners in spite of being served only a 600 calories-per-day diet for extended periods of time. It was during this time that Cochrane performed his first trial. He conducted a non-random trial involving 20 subjects to convince the Germans that a yeast supplement to the prisoner diet would cure the widespread oedema amongst them. In spite of the lack of scientific rigor, Cochrane succeeded in convincing the Germans. He later described the venture as his “first, worst, and most successful trial.” It was also during this time that Cochrane realized the extent to which unsubstantiated claims plagued medicine. As Cochrane reveals, “I had considerable clinical choice of therapy: my trouble was that I did not know which to use and when.” This frustration planted the seeds for a lifelong journey of trying to distinguish between scientifically valid medical therapies and the invalid ones.
After returning from the war, Cochrane trained as an epidemiologist. His training involved spending a year in the Henry Phipps Institute, Philadelphia and receiving tutelage from Sir Bradford Hill, who pioneered the RCT and was the first to demonstrate a connection between cigarette smoke and lung cancer. He started his career by studying whether pneumoconiosis progresses to Progressive Massive Fibrosis (PMF) as a result of tuberculosis in coal miners. Although the experiment did not produce conclusive results because the prevalence of tuberculosis fell spontaneously in the control population, Cochrane did manage to achieve response rates close to 100%, and his study was the first to use a whole population in a controlled experiment. It was the high response rates that earned Cochrane the reputation of being an excellent epidemiologist. In the sixties, he left the pneumoconiosis research unit to work as a David Davies professor of tuberculosis and chest diseases at the Welsh National School of Medicine. He also served as the honorary director of the Medical Research Council Epidemiology Unit during this time. As well as maintaining his expectations of a high response rate in epidemiology studies, he was offered a Rock Carling Fellowship to write a book about evaluating the British National Health Service (NHS). In 1971 he published his ground-breaking monograph, Effectiveness and Efficiency: Random Reflections of Health Services.
Archie Cochrane is best known for his influential book, Effectiveness and Efficiency: Random Reflections on Health Services published in 1972. The principles he set out in it were clear and straightforward: he suggested that because resources would always be limited, they should be used to provide only 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 (RCTs) 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 a manner appropriate for someone writing on the topic of the biases and inconsistencies in medicine, Cochrane began the book by first revealing his own biases. He used the terms effectiveness, efficiency and equality as his yardstick for evaluating the NHS. Effectiveness was used as a measure of how much a medical activity changes the natural course of a disease in a RCT. Efficiency was used to refer to how well the health care system utilized resources such as doctors, nurses, medical equipment, etc. to implement an effective medical intervention. Equality was used to assess care and the variation of care amongst different hospitals.
Cochrane believed that the ultimate duty of medical doctors was to make decisions between alternative therapies based on cost/benefit comparisons. According to him, “these can really only be obtained by an adequately costed RCT.” However, even he realized that RCTs did not always provide an unequivocal answer. One can easily imagine a scenario in which different RCTs provide contradictory results. This was the case with RCTs performed to evaluate the benefit of tonsillectomies. Cochrane found that while one RCT found tonsillectomy to be a beneficial procedure with regards to otitis media, another RCT found no associated benefit. Cochrane realized that clinicians would not find a litany of RCTs helpful and would not necessarily know which trial was the best. This led Cochrane to reach the conclusion in 1979 that “It is surely a great criticism of our profession that we have not organized a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomized control trials.” His challenge led to the establishment during the 1980s of an international collaboration to develop the Oxford Database of Perinatal Trials. This call for an organized database of RCTs served as an impetus for the formation of the first Cochrane centre (in Oxford, UK) in 1992, the founding of The Cochrane Collaboration in 1993, and ultimately the creation of Evidence Based Medicine.
Archie Cochrane fought ardently for his ideals, regardless of whether they were about politics or healthcare. His self-written obituary ended as follows: “He was a man with severe porphyria who smoked too much and was without consolation of a wife, a religious belief, or a merit award—but he didn't do so badly.” He died on 18th June 1988. One Man's Medicine: Autobiography of Professor Archie Cochrane was published in 1989.