Morabia, Alfredo

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Book review l BuchbesprechungArchibald Leman Cochrane 1909–1988: a meaningful life in science and historyAlfredo MorabiaService d’épidémiologie clinique, Hôpitaux Universitaires de GenèveAndre Breton, and the surrealist movement, called a livre-objet, a book that was a piece of art in its form and not onlyin its content (Picture 1). Xavier Bosch has produced a won-derful livre-objet on Archie Cochrane, entitled: “ArchibaldCochrane: back to the front” (Picture 2) (Bosch 2003). It haspictures, testimonies, citations of historians and novelists.The book is a passionate tribute to Archie Cochrane, theBritish epidemiologist whose name has become the rallyingpoint of people throughout the world who collaborate toprepare, maintain, and disseminate systematic reviews of theeffects of healthcare interventions. The title “Back to the front” may sound surprising for thebiography of an epidemiologist. Which front? Which battle?Actually, there were many fronts and many battles inCochrane‘s life. The first took place in 1937 Catalonia, when Cochranejoined the Republicans to fight the anti-democratic army ledby General Bahamonde Franco. This was a very dramaticmoment in European history. In the 1930s, Hitler had seizedpower in Germany, and Mussolini in Italy. Franco, followingtheir path, was attempting to defeat the young SpanishRepublic. The leftist parties, mainly the communists, orga-nized groups of volunteers to go and fight on the side of therepublicans. Others went to Spain spontaneously. Betweenthe autumn of 1936 and the autumn of 1938, about 50 000volunteers joined these International Brigades. Theirpremises were right. At the very beginning of his military rebellion, Franco wouldhave had no chance to overthrowing the young Republic hadhe not had massive help from the fascist governments inGermany and Italy (Bolloten 1991). In July 1936, the Spanish navy had refused to join the sedi-tious officer corps, so that Franco depended entirely on thepilots and planes provided by Hitler and Mussolini to enablehis African Army to cross the Strait of Gibraltar (Bolloten1991). On the other hand, no government appeared ready tohelp the legal Republican authorities sufficiently to enablethem to win the war. Even the soviet republic, the USSR,which had been the strongest supplier in experts andresources, limited its help to what was needed to prevent thecollapse of the Republic, not to guarantee its victory. TheInternational Brigades fought in Spain for about two years.They made an impressive contribution to the defense ofMadrid from the autumn of 1936 to the spring of 1937 (Bol-loten 1991). Among those who went to Spain to defend the Republic wasArchie Cochrane. He had driven there in his car and servedas a doctor. He was one of a generation of young British doc-Soz.- Präventivmed. 49 (2004) 416– 4180303-8408/04/060416–3DOI 10.1007/s00038-004-4058-y© Birkhäuser Verlag, Basel, 2004417Book review l BuchbesprechungSoz.- Präventivmed. 49 (2004) 416– 418© Birkhäuser Verlag, Basel, 2004Alfredo MorabiaArchibald Leman Cochrane 1909–1988: a meaningful life in science and historytors, and more generally scientists, in the 1930s believing insocial justice and willing to combat fascism actively. In thiscontext Cochrane and other epidemiologists-to-be emergedas militants acting in solidarity with the Spanish Republic.Among them was Sir Richard Doll who tells his own story inthe book (Bosch 2003).But the sacrifices of the International Brigades were wast-ed. Since August–September 1936, abandoning the Repub-lic, Britain and France had called for all countries in Europenot to intervene in the Spanish Civil War. Eventually27 countries including France, Britain, Belgium, Nether-lands, Russia, the Soviet Union, Portugal and Swedenjoined this Non-Intervention Committee. Germany andItaly formally subscribed to the agreement. In September1938, the withdrawal of foreign volunteers from Spainby the Republican authorities was a last, desperate attemptto win the support of the Western governments. TheRepublic collapsed, opening the way to the Second WorldWar. World War II started shortly after the final victory of Francoand created Cochrane’s second front. He joined the army,was captured and became responsible for the health care ofprisoners of war in Salonica, Greece. The book reproducesthe section of Cochrane’s autobiography (Cochrane &Blythe 1989; Cochrane 1984) in which he tells the story of atherapeutic trial he conducted in the camp. When a numberof men developed heavily swollen ankles, Archie diagnoseda protein deficiency and experimented to find the besttreatment. Cochrane knew the story of James Lind, aScottish naval doctor who, two centuries earlier, had report-ed a controlled comparison of treatments for scurvy, show-ing the effectiveness of oranges and lemons (Lind 1753).Cochrane was also aware of a disease called beriberi, stem-ming from a deficit in vitamin B. In 1929, Eijkman hadreceived the Nobel Price for his groundbreaking laboratoryexperiments showing that beriberi was a nutritional disease(Carpenter 2000). A successful clinical test indicating thatvitamin B1 was effective against beriberi was reported in1937, while Cochrane was in Catalonia. Yeast is an impor-tant source of vitamin B1 and one of the best ways to treata deficit. All this was in Cochrane’s mind when he chose20 men with severe swelling, and allocated them alternatelyto one or other of two small wards. Those in one wardreceived three daily portions of protein-rich yeast, whichCochrane had bought on the black market. Those in theother ward received one vitamin C tablet daily out ofArchie’s small emergency reserves. By the fourth day, eightout of 10 men in the yeast ward felt better, but no one in thevitamin C room. Here is Cochrane‘s own account of theepisode:“Then I remembered having read about ‘wet beriberi’ caused byvitamin B deficiency, which resulted in severe edema. For a timeI must have convinced myself that I was witnessing an epidemicof ‘wet beriberi’, for I decided to do an experiment modeled onthat of James Lind, one of my medical heroes. I chose 20 men, allin their early twenties, all emaciated and with edema above theknee. I put 10 in each of two small wards. They all received thestandard rations, but those in one ward were given a supplementof yeast three times a day (I had to use my own reserve of Greekmoney to get it on the black market). In the other ward they gotone vitamin C tablet each day (I had kept a small reserve foremergency). (…). Eight out of ten men in the ‘yeast room’ feltbetter, while no one felt better in the ‘vitamin C room’.”(Bosch2003: 202–3).After the war, Cochrane’s front moved to Britain. The Span-ish Civil War and of course World War II had resulted in agood deal of disillusionment among the young people whowished to see more social justice and democracy. But therewere new opportunities in the British society, which hadgone through a process of modernization since the mid-1930s and had been able to mobilize its industry and its tech-nological superiority (e.g., cars, radar, electric equipments,planes) for the war effort. Britain’s war-planned economyhad slanted towards social justice (Hobsbawm 1996).Keynes’s economic theories suggesting that internal, state-controlled mechanisms rather than colonial expansion andexploitation could foster economic growth were gainingaudience (Keynes 1936). The 1942 Beveridge Report statedthat: “Medical treatment covering all requirements will beprovided for all citizens by a national health service organ-ised under the health departments and post-medical rehabil-itation treatment will be provided for all persons capable ofprofiting by it” (Beveridge 1942). Winston Churchill, a con-servative and UK Prime Minister since 1940, lost Britishgeneral election of July 1945 to Labour’s Clement Attlee.The time had come to deliver social promises in practice.This idea was already present in a 1944 booklet entitled“Health” by Jerry Morris, later the author of the influentialtextbook “Uses of epidemiology”: the world had to becomebetter after the defeat of Hitlerism (Smith 2001). In this con-text, the internationalist generation of the 1930s refocusedits energy, fighting for public health, more equality in theaccess to health care, and a National Health Service. Epi-demiology provided the concepts and methods for pursuingthese new objectives. The discipline helped to identify themodifiable causes of ill health, and to improve those livingand occupational conditions which affected the poorer sec-tors of the society. The work of Austin Bradford Hill,Richard Doll, Jerry Morris, Archie Cochrane and many oth-Book review l BuchbesprechungSoz.- Präventivmed. 49 (2004) 416– 418© Birkhäuser Verlag, Basel, 2004418 Alfredo MorabiaArchibald Leman Cochrane 1909–1988: a meaningful life in science and historyers, all more or less inspired by socialist ideals, is a testimo-ny of this. Greater social equity also meant better distribution of care.And in a country with limited resources (the UK had ceasedto be, after World War II, the major economic power it oncehad been), better distribution meant identifying effectivetreatments and concentrating economic resources on these.The Beveridge Report should have referred to all “effective”treatments. This is the origin of Cochrane’s campaign toevaluate treatment and preventive practices using appropri-ate methods, among which randomized controlled trialsplayed a central role. On this new front, Cochrane was anefficient propagandist (Cochrane 1972), his ideas leadingsoon after his death to the international collaboration thatbears his name.When I closed “Back to the front”, I had the feeling, wrong-ly or rightly, that the Spanish Civil War had played a pivotalrole, not only in European history but also in the history ofepidemiology. The 1930s released a tremendous energy insome sectors of European youth, which expressed itself inthe anti-fascist solidarity and later in the fight against healthinequalities. This lead to the emergence of a new generationof British epidemiologists, thanks to whom our disciplinehas reached unprecedented levels of rigor and theory andhas started to play a major role for the public health. In conclusion, here is a book with many facets. It is, first ofall, the homage of free Catalan epidemiologists to a Britishepidemiologist who stood up for a free Catalonia. It isalso a book about Archie Cochrane’s contemporaries, ageneration of British epidemiologists, which brought theirdiscipline to new levels of efficiency and formalism andcontributed to discoveries of great relevance to publichealth. It is finally a book on a person with a very uniquepersonality, a romantic existence and inspiring ideas.Cochrane’s was a life that made sense both in science and inhistory. AcknowledgementsI am indepted to Jean Baton, Iain Chalmers, MichaelCostanza, Miquel Porta and Séverine Schusselé-Filletazfor their insightful comments on an earlier version of thismanuscript.ReferencesBeveridge W (1942). Social and allied services(The Beveridge Report). http://www.fordham.edu/halsall/mod/1942beveridge.html.Bolloten B (1991). The Spanish Civil War: revolution and counterrevolution. Chapel Hill:University of North Carolina Press.Bosch FX (2003). Archie Cochrane: back to thefront. Barcelona: Ajuntament de Barcelona, TheCochrane Collaboration, Institut Catalàd’Oncologia.Carpenter KJ (2000). Beriberi, white rice, andvitamin B: a disease, a cause and a cure. Berkeley: University of California Press.Cochrane AL (1972). Effectiveness and efficien-cy: random reflections on health services. London: Nuffield Provincial Hospitals Trust. Cochrane AL (1984). Sickness in Salonica: myfirst, worst, and most successful clinical trial.BMJ Clin Res Ed 289: 1726–7.Cochrane AL, Blythe M (1989). One man’s medicine: autobiography of professor ArchieCochrane (The Memoir Club). London: BMJPublishing Group.Hobsbawm E (1996). The age of extremes. NewYork: Vintage Books.Keynes JM (1936). General theory of employ-ment, interest and money. London: MacmillanCambridge University Press for Royal EconomicSociety.Lind J (1753). A treatise of scurvy. Edinburgh:University Press (1953).Smith GD (2001). The uses of “Uses of epidemi-ology”. Int J Epidemiol 30: 1146–55.Address for correspondenceProf. Alfredo MorabiaSerrice d’épidémiologie clinique25 Rue Micheli-du-Crest1205 GenevaSwitzerlande-mail: alfredo.morabia@hcnge.ch

Archibald Leman Cochrane 1909-1988: a meaningful life in science and history

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Archibald Leman Cochrane 1909-1988: a meaningful life in science and history

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