The Cochrane Collaboration celebrates 20 years

How can we have a rational health service if we don’t know which of the things being done in it are useful and which are useless or possibly even harmful? — Archie Cochrane

When Julia Fullerton-Batten went to photograph Sir Iain Chalmers in Oxford, United Kingdom, in 2006 for a collection of modern-day health care heroes destined for the National Portrait Gallery in London, UK, she wanted to depict him in his own working environment. The British obstetrician and health services researcher, one of the cofounders of The Cochrane Collaboration, insisted that he be shown alongside his colleagues. The resulting photo shows him in his office surrounded by 149 portraits — of his colleagues, his mentors, his family and the others who influenced him — splayed across the floor, the filing cabinets, the walls and even the ceiling. It’s a striking tribute to the success of teamwork.

Teamwork is still central to The Cochrane Collaboration, which is celebrating its 20th anniversary at its annual colloquium in Québec City, Quebec, Sept. 19–23, 2013. From a handful of physicians, lay people, researchers and policy-makers who gathered in Summertown Pavilion in Oxford in October of 1993, The Cochrane Collaboration now consists of 53 review groups, each focused on a specific topic. Altogether, Cochrane has produced more than 5500 systematic reviews of reliable, high-quality studies. These reviews are the key output of the 31 000 or so mostly volunteers who systematically gather and assess studies behind particular interventions, with the goal that all health care decisions would be informed by synthesized, up-to-date research. The impact is impressive at the bedside and beyond; many researchers begin by examining the existing systematic literature, which usually involves a search of The Cochrane Library.

Iain Chalmers poses in his office with 149 portraits of colleagues, mentors, family and others who influenced him. The portrait speaks to the collaborative spirit of Cochrane.

Image courtesy of © Julia Fullerton-Batten/National Portrait Gallery, London, United Kingdom

Chalmers first saw the need for systematic reviews long before the term was coined. In the 1970s, while working in the Gaza Strip, he had no idea how to sort through the range of options for treating a particular illness; his medical training had left him ill-equipped to judge which option was right. Reading the Scottish epidemiologist Archie Cochrane’s 1972 book Effectiveness & Efficiency: Random Reflections on Health Services, with its emphasis on randomized controlled trials (RCTs), was “like finding a compass in the jungle,” and gave him a sense of where to look for reliable information when faced with conflicting clinical opinions.

By the mid-1970s, Chalmers and his colleagues were searching earnestly for RCTs on all aspects of his chosen métier — obstetrics — scouring bibliographic databases, hand-searching journals and resorting to some very unusual methods to identify RCTs. For example, in this pre-Internet era, his team wrote letters to 60 000 obstetricians and pediatricians worldwide to track down and systematize the literature in perinatal medicine. This led to the publication of the massive two-volume book, Effective Care in Pregnancy and Childbirth (coedited by Murray Enkin and Marc Keirse), a landmark in evidence-based health care. Above all, it was proof of what could be done, and the year before his death in 1988, Cochrane himself praised this achievement, jibing that it would be nice to see this kind of rigour applied to all of medicine.

The creation of the collaboration was the answer to Cochrane’s jibe.

Despite its massive growth and professionalization — there is now a CEO, an editor-in-chief of the online product, a social media team and The Cochrane Library — no simple formula can explain the collaboration’s success over these last 20 years. Certainly the agility of a virtual organization which doesn’t produce a paper product, and its reliance on the labour and enthusiasm of thousands of people worldwide are key features.

During ward rounds in early 1990s, Dr. David Sackett resorted to an “evidence cart” — including a laptop hooked to a projector — to access MEDLINE and other databases for instructing students. He always alluded to the “generation of the necessary evidence and its integration,” precisely what the fledgling collaboration was doing in its systematic reviews.

Image courtesy of David Sackett

Canadians who have been with the collaboration from the very beginning include Murray Enkin, Brian Haynes, Gordon Guyatt, Alex Jadad, David Sackett, Peter Tugwell and many others who are now prominent in the world of evidence-based medicine, and who provided some of the impetus needed to get the collaboration airborne.

Sackett, who founded Canada’s first department of clinical epidemiology, as well as the Centre for Evidence-Based Medicine at the University of Oxford, also chaired the collaboration’s first steering group (1993–95). In the early 1990s, Sackett was out on the road showing how evidence-based medicine could work in practice. With the aid of his “evidence cart” — which featured a laptop hooked to a projector — he accessed MEDLINE and other databases to instruct students who were working on the wards. In these bedside rounds he always came back to the “generation of the necessary evidence and its integration,” the perfect segue to the need for systematic reviews now being prepared by the fledgling collaboration.

Another active Cochranite, Brian Haynes, did seminal work in ensuring that the reviews were accessible to physicians. Haynes helped found the popular ACP Journal Club in the mid-1990s. It became one of the forerunners of a new industry producing brief, digestable reports for physicians based on systematic reviews of evidence.

In those early days, the collaboration desperately needed financial support to accomplish the huge task it had set for itself. An initial £75 000 grant from the Swedish Council on Health Technology Assessment helped get the early Cochrane network up and running and its second colloquium was held in Hamilton, Ontario, in 1994.

Gordon Guyatt, a McMaster professor of medicine, has been with the collaboration from those early days and says the organization’s biggest challenge has always been to “stay relevant and viable.” Finances have always been an ongoing challenge, partly because very early on the group’s leadership took a strong stand against pharmaceutical industry donations, keeping the reviews free from a major source of bias. The collaboration has been supported by governments, research agencies (Canadian Cochrane groups receive a total of about $2 million annually from the Canadian Institutes of Health Research) as well as sales of national licences to The Cochrane Library.

It is not just researchers, health professionals or policy-makers who create Cochrane systematic reviews. From the very beginning, the collaboration has made strenuous efforts to include consumers, inviting lay people to help create reviews and to comment on completed ones. Jeremy Grimshaw, who is currently co-chair of Cochrane’s Steering Group and director of the Canadian Cochrane Centre in Ottawa, Ont., thinks the major challenge in Cochrane’s future is making sure that this unique organization can talk to all these different audiences at once.

Iain Chalmers, now more than 10 years out of the collaboration, says that he’s happy that a “generosity of spirit” still seems to inhabit the collaboration. This generosity continues to help the collaboration expand, and bring in newcomers from around the world. Teamwork has continued to build and strengthen an enterprise that a Lancet editorial said “rivals the Human Genome Project in its potential implications for modern medicine.”1

Jini Hetherington, one of the faces in that Chalmers portrait, said she was one of the “absolutely mad” people helping Chalmers’ team write letters to thousands of obstetricians and pediatricians around the world. She has been to all 20 colloquia, and says a memorable highlight for her was at the Freiburg colloquium in 2008, looking at all the participants gathering during a coffee break. Expecting a sea of grey hair, the number of young people she saw floored her. She said: “There was a time when we worried whether [the collaboration] might just be for old fogies like myself. A large part of the value of the colloquium is bringing in new people, getting new ideas, fresh enthusiasm.”

Grimshaw hopes the colloquium in Québec continues to attract new people: “My experience is that when people first attend a Cochrane colloquium they are completely blown away by it. All of a sudden, they see this amazing group of people committed to a vision, with great passion and humour. And once you get into the organization, it’s very hard to detach because you get very carried away with the culture.”