Research Methods & Ethics · 1972
Cochrane, 'Effectiveness and Efficiency'
Effectiveness and Efficiency: Random Reflections on Health Services
In 1972, most medical treatments had never been evaluated in a randomized controlled trial. Surgery, drug prescribing, obstetric practice, and rehabilitation routines accumulated through tradition, authority, and anecdote. The NHS had been spending public money for a quarter century on interventions whose efficacy was largely untested. Archie Cochrane, a Welsh epidemiologist who had run clinical trials in prisoners-of-war and later led the MRC Epidemiology Unit in Cardiff, decided to say so in print.
His monograph, Effectiveness and Efficiency: Random Reflections on Health Services, ran to 89 pages and was published by the Nuffield Provincial Hospitals Trust in 1972. The argument was blunt: the health service lacked the information to allocate its resources rationally, and the only reliable way to obtain that information was through randomized trials with clinically meaningful endpoints. Cochrane named specific specialties he considered evidence-poor, with obstetrics receiving particular attention. He described the failure to evaluate perinatal care as a public health problem, not merely an academic gap.
The book was polemical rather than systematic, and Cochrane himself would later admit that obstetrics, the specialty he had criticized most pointedly, was ironically better represented in the trial literature than many others. The critique stung precisely because it came from within the medical establishment, from a physician who had practiced and done research. Colleagues found the book uncomfortable, which was part of the design. It reached policymakers and practicing clinicians in a way that technical epidemiological papers did not.
Cochrane's specific proposal was that systematic reviews of all RCTs for each clinical question should be compiled and kept current. He had no mechanism to implement this; he was arguing for an infrastructure that did not exist. In 1979 he called the failure to produce a systematic review of perinatal RCTs a 'great indictment' of the profession. Iain Chalmers took up that challenge in the 1980s, assembling the Oxford Database of Perinatal Trials and eventually founding the Cochrane Collaboration in 1993, named explicitly in Cochrane's honor.
The Cochrane Collaboration formalized the systematic review as a scientific product, developed standards for meta-analysis, and created a publicly accessible library. By 2024 it maintained more than 8,000 reviews covering most major clinical questions across medicine. Cochrane died in 1988, five years before the organization bearing his name was established.
Key People
- Archie Cochrane — British epidemiologist and author; advocate for RCT-based evaluation of health services.
- Iain Chalmers — Epidemiologist who founded the Cochrane Collaboration in 1993, building Cochrane's vision.
Cochrane AL. Effectiveness and Efficiency. Nuffield Provincial Hospitals Trust, 1972
Related landmarks
- 1972 · Tuskegee Syphilis Study Exposed (Research Methods & Ethics)
- 1976 · Large simple trials and trial overviews (Peto and colleagues) (Research Methods & Ethics)
- 1964 · Declaration of Helsinki (Research Methods & Ethics)
- 1962 · Kefauver-Harris Drug Amendments (Research Methods & Ethics)