Mark Wilson
Opening of the Caribbean Branch of the US Cochrane Centre
6th June 2013
First, let me say what a pleasure and a privilege it is to be with you on this very special day.
I was asked to speak about how we got here – the history of the Cochrane Collaboration, its evolution
and impact on health practices – and where we are going – our future direction, the new opportunities
and challenges we face.
1.
How did we get here?
As the programme brochure explains, The Cochrane Collaboration is named after Archie Cochrane, a
British doctor and epidemiologist who was active in medical practice and research from the 1930s to his
death in the late 1980s. He is best known for his influential book, Effectiveness and Efficiency: Random
Reflections on Health Services. In it he suggested that because health resources would always be limited,
they should be used to provide those forms of healthcare which have been shown - in properly designed
evaluations - to be effective. In particular, he stressed the importance of using evidence from
randomized controlled trials (commonly known as RCTs) because these were likely to provide much
more reliable information than other sources of evidence. “It is surely a great criticism of our
profession,” he subsequently wrote, “that we have not organized a critical summary, by specialty or
subspecialty, adapted periodically, of all relevant randomized controlled trials.”
Effectiveness and Efficiency was originally published in 1972, but over forty years later it is still fresh and
engaging and I’m delighted to announce that this year The Cochrane Collaboration will be digitally
republishing the book with a new Foreword by our Co-Chairs, Jeremy Grimshaw and Jonathan Craig. It is
– in many respects - our founding charter, a call to arms that was read by doctors all over the world and
which planted the seeds in the minds of a few who, over time, began talking about how to respond to
the challenge effectively. Of course, pre-eminent amongst that new generation was Iain – now Sir Iain –
Chalmers: a brilliant doctor, impassioned writer and quite astonishing force of nature! Some of you
know Iain Chalmers far better than I do, and he gathered a small group of like-minded clinicians,
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researchers, academics and policy makers together to form The Cochrane Collaboration in the early
1990s to take up Archie Cochrane’s challenge and embed evidence-based medicine in policy and
practice.
The critical importance of undertaking this work is encapsulated in The Cochrane Collaboration’s logo.
The inner part of the logo illustrates a systematic review of data from seven RCTs, comparing one
healthcare treatment with a placebo. This diagram shows the results of an early Cochrane Review,
examining RCTs of a short, inexpensive course of a corticosteroid given to women about to give birth too
early. The first of these RCTs was reported in 1972. Over the following 20 years, a number of additional
studies were conducted examining the same treatment. Over time the evidence indicated, through
systematic review, that treatment of pregnant women with corticosteroids reduces the odds of their
babies dying from the complications of prematurity by 30 to 50 per cent. But until a systematic review of
these trials was published, most obstetricians were unaware that the treatment was so effective, and it
was not widely used. As a result, it is likely that tens of thousands of premature babies suffered and died
unnecessarily (and needed more expensive treatment than was necessary).
This example is one of many illustrating the human costs resulting from failure to perform systematic,
up-to-date reviews of RCTs of health care – and the powerful impact of evidence on guidelines, on
practice, and on mortality rates. It is the driving force behind The Cochrane Collaboration’s vision:
“…that healthcare decision-making throughout the world will be informed by high-quality, timely
research evidence. We will play a pivotal role in the production and dissemination of this evidence
across all areas of health care.”
Today, more than 20 years after the initiative inspired by Archie Cochrane and bearing his name, The
Cochrane Collaboration is an established international organization with more than 28,000 volunteers
working in 120 countries. There are now 53 subject-based Cochrane Review Groups, 16 specialised
Methods Groups and 12 thematic Fields and Networks. Their work is supported by 500 people employed
on behalf of the organization around the world and in the Collaboration’s central offices in Oxford and
London. The Collaboration has now published more than 5,300 reviews and 2,300 protocols in The
Cochrane Library, along with 700,000 records in the Cochrane CENTRAL Register of Controlled Trials.
Last year, nearly five and a half million full text downloads of Cochrane Systematic Reviews from The
Cochrane Library were made; and usage of the Library went up by 25% on that in 2011. The
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Collaboration’s growth, development, outputs and contribution to modern medicine over the last 20
years is truly astonishing – something we can be immensely proud of.
But the path to where the Collaboration is now has often been an uphill climb, and there have been
substantial obstacles along the way. From the very beginning, the founders of The Cochrane
Collaboration encountered philosophical opposition from members of the medical community, many of
whom were challenged or affronted by the idea of evidence-based medicine – that amassing and
examining evidence could legitimately undermine beliefs and practices they had learned in medical
school and utilized in their professional careers. The founders of The Cochrane Collaboration were
generally considered upstarts, mavericks and renegades in the wider healthcare community, dedicated
to an esoteric idea and prone to cultish behavior.
This, inevitably, had financial repercussions, particularly in the early days of the Collaboration. Funders
of health services and research institutions either didn’t know about the concept of systematic
compilation and assessment of evidence, or didn’t understand its potential impact on practice. Research
institutions did not consider conducting systematic reviews - which consisted mainly of evaluating other
people’s primary research - to be legitimate research in itself, worthy of financial support or of academic
attention. This made funding difficult to obtain at the organizational level, and for individual Cochrane
contributors. Healthcare professionals, particularly those working in academic disciplines, often found
the response to their Cochrane involvement discouraging for the same reasons. At best, preparing
systematic reviews was not considered to be as valuable as primary research; at worst, it was viewed as
poaching other people’s work; and across the board it was unlikely to be considered a legitimate use of
academic research time or a stepping-stone to academic achievement.
Then, as now, the Collaboration’s greatest asset in overcoming obstacles in its path was the
determination, dedication, and enthusiasm of its contributors. In the early days, when members of the
funding, academic, and healthcare communities were unaware of or unconvinced by the arguments in
favor of an evidence-based approach, Cochrane collaborators across the organization made two critical
contributions:

First, they contributed their time and efforts, generally working for little or no money, to help
increase the critical mass of systematically reviewed Cochrane evidence;
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
Second, they worked to raise awareness in their own organizations - to make people aware of why
systematically reviewed evidence was important and, if they succeeded in convincing them, making
them aware of how and where to find it and use it.
As a result, attitudes and practices have changed over time, as evidenced by two telling examples: the
first involves The Lancet, one of the UK’s most prestigious medical journals. In the early days of the
evidence-based medicine movement, The Lancet published an editorial hostile to the very concept. By
1995, it had hailed The Cochrane Collaboration as “an enterprise that rivals the Human Genome Project
in its potential implications for modern medicine”, and in 2005 it announced that authors submitting
manuscripts reporting clinical trials would henceforward be required to include a clear summary of
previous research findings, ideally by direct reference to a systematic review.
The second example involves the Impact Factor. This measurement, as most of you will know, assesses
the frequency of citations of academic journals and is calculated annually by the Institute for Scientific
Information. It is widely recognized in the research community as a standard for ranking and comparing
journals, and is considered as part of grant evaluation and research assessment processes. In the earliest
days of The Cochrane Collaboration, when the value of systematic reviews had not yet been widely
recognized, The Cochrane Library was not evaluated as part of the ISI’s Impact Factor assessment. As The
Cochrane Library’s scope and reputation increased, so did its level of citations, and in June 2008 the ISI
recognized its importance by granting the Library an Impact Factor ranking. This now stands at 5.9; and
The Cochrane Library is the tenth-most cited medical journal in the world.
The Cochrane Collaboration’s impact on health practice has been gradual but pervasive. From being an
abstract and unfamiliar concept, ‘evidence’ has become a way of thinking for people involved in
healthcare at every level. The Collaboration’s principles of promoting access and enabling wide
participation have made evidence-based healthcare an approachable and applicable concept for
patients and clinicians, journalists and researchers, policy makers and funders.
One of the Collaboration’s principal goals is to make Cochrane evidence available to end users via oneclick access. In 2003, 10 years after the Collaboration’s foundation, we signed our first publishing
agreement with John Wiley & Sons. This agreement moved the Collaboration’s publishing platform from
its original location – a small, Oxford-based digital publisher that had been instrumental to the early
growth of the Collaboration’s technical infrastructure and publishing output – to a major international
company with a worldwide reputation for excellence in digital and scientific publishing. This relationship
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has given the Collaboration unprecedented opportunity to make Cochrane evidence available and
accessible to a global audience. Now, in more than 100 countries worldwide, access to The Cochrane
Library is provided without charge, making Cochrane evidence freely available to every citizen of those
countries. Throughout the Caribbean and Latin America, access is freely available via the Virtual Health
Library, thanks to funding provided by BIREME, the Pan American Health Organization and the World
Health Organization. And in some 20 other countries worldwide, including Australia, India, and the
United Kingdom, nationwide access to Cochrane evidence is provided by government funding.
Providing access is only one facet of The Cochrane Collaboration’s partnership with the World Health
Organization. This partnership, established in 2011, allows the Collaboration to promote evidence-based
health care at the highest levels of international policy-making, and includes a seat on the World Health
Assembly. Formalizing this partnership gives us the opportunity to expand our collaboration with WHO,
which is already well established through initiatives such as the Reproductive Health Library. This
resource has helped millions of women and babies in low- and middle-income countries through
practice recommendations on newborn health, pregnancy and childbirth, and sexually transmitted
infections.
Another area in which Cochrane evidence has had a significant impact is in informing the development
and implementation of national guidelines for practice. In the United Kingdom, the National Institute for
Health and Clinical Excellence (also known as NICE), which develops guidelines for clinical practice
throughout the National Health Service, works to ensure that Cochrane evidence underpins guidance
wherever possible. Since 2008, NICE has published nearly 100 guidelines in which 500 Cochrane Reviews
are cited: with 73% of the guidelines citing at least one Cochrane Review (and one of them cites 46!).
This is a clear demonstration of the impact of Cochrane evidence on healthcare practice and the return
on investment in Cochrane research made by the UK’s Department of Health since the Collaboration’s
earliest days.
2.
Where are we going?
I have been speaking about our past and our present – what about the future? This year, even as The
Cochrane Collaboration celebrates its 20th anniversary, we are turning our focus on some substantial
challenges, both inside the organization and in the industries and communities with which we work, as
we establish our new Strategy to 2020, which I hope we will finalise at the Collaboration’s annual
Colloquium in Quebec, Canada, in September.
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The two main motifs of the new strategy are already clear:
Firstly, An External Focus: we need as an organization to be much more oriented to the users of our
Systematic Reviews and evidence-based products and services.
Secondly, after Archie Cochrane’s book title, Become more Effective and Efficient Internally: Whilst
keeping the dynamism and creativity that has made the Collaboration what it is, we need to become
more supportive, effective and efficient in the way that we work and create and deliver those products
and services.
I have highlighted the astonishingly effective ways in which the Cochrane has impacted on the world.
This must be our future main driver – the beginning and end of all of our thinking. We must adopt an
‘outside-in’ approach which starts with the needs of the global audience of end-users of Cochrane
evidence and the uses to which they put our work. We want Cochrane Reviews to be the first choice for
answering any healthcare-related question. In working towards this goal, we will seek to produce
reviews that are always relevant, timely and of high quality. How does that change how we produce,
deliver and present synthesized evidence? Are we answering the questions these end users are asking,
at the right time and in the right way? Are we giving clinicians, researchers, patients, carers and health
policy makers the information they need it and in a form which is most useful to them? As large as we
have grown, and as enthusiastic as our contributor base is, our resources are not unlimited, and as we
continue to grow we must grapple with balancing the need for maintaining our broad coverage of
healthcare areas with identifying and addressing priorities for particular user groups: whether their
needs are determined by geographical setting, resource restrictions, acute situations, or any of the host
of other considerations that drive healthcare research, policymaking and practice.
The information revolution has brought a transformation in the way research information can be made
available to end users. The growth of Open Access across scientific and medical publishing presents a
considerable challenge to traditional publishing frameworks, with the costs moved from readers and
users of information and intellectual property to those who produce it. This is a challenge the
Collaboration has already begun to address. Working with our long-term publisher, John Wiley, with
whom we signed a new publishing contract earlier this year, we have introduced a two-tier model aimed
at increasing open access to Cochrane evidence. This framework represents an important development
for the Collaboration, but it is only a first step towards what is likely to be a substantially different
publishing model.
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This move towards an Open Access model also has significant financial implications for the
Collaboration. Revenues from The Library have grown enormously over the last decade and this growth
has fostered investment in the Collaboration’s infrastructure aimed at supporting the work of Cochrane
contributors worldwide. I’ve just flown down from New York where we have been working on how we
can develop The Cochrane Library in the coming years and new derivative products and services which
will sustain the organization in the future whilst meeting our goal to make Cochrane Systematic Reviews
freely available for the whole world.
How the Collaboration produces synthesized evidence more efficiently and effectively is the second
main motif of the new strategy. We must, for example, get better at making the experience of writing
and producing a Cochrane Systematic Review easier, faster and more enjoyable. By doing so we will
retain and build expertise and capacity, and ultimately improve the quality of our outputs. We will be
looking at every stage of our production process, at our organizational structure, at how we coordinate
and communicate with each other, and how we continue to ensure that ‘Cochrane’ remains the
watchword for high-quality systematic reviews. We will be helped by new technological opportunities.
The Collaboration was a pioneer in the use of electronic publishing technology and we are already at the
leading edge of using ‘Linked Data’ technology to present content in innovative ways, tailoring it to the
needs of a growing number of audiences. We will invest in the technology that is central to this
approach and embrace new tools, processes, and interfaces to facilitate the completion of reviews,
mitigate workloads for Cochrane contributors, and maximize the usability of Cochrane evidence.
In facing these challenges, we must not lose sight of the fact that the quality and applicability of
Cochrane evidence remains paramount. Recent events have highlighted the ongoing issue of unreported
trial data, and the growing awareness worldwide that data from thousands of clinical trials remain
unavailable to researchers, clinicians, and the public. Without complete information from trial results,
information is lost, bad treatment decisions may be made, opportunities for better and more effective
treatment are missed, and trials are repeated unnecessarily, duplicating effort and wasting resources.
Cochrane Reviews cannot hope to provide a comprehensive picture of the evidence available if 50% of
trial data, as is often estimated, remains unreported. To raise awareness and promote action on this
issue, the AllTrials initiative was formed earlier this year. The Cochrane Collaboration is a principal
supporter and organizer of the initiative, marshaling the collective strength of our worldwide
representation to bring international attention to this issue.
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The Cochrane Collaboration will also become a truly global organization. Today is part of that process,
and I am thrilled that this new Caribbean branch will become a bridgehead for the promotion of
evidence-based healthcare in the region and as a way to expand our profile and impact in the lives of
the millions of people who need and deserve the most effective healthcare that improves their lives.
Not only will Cochrane break out of its traditional geographic areas of strength, but we will be investing
in much greater translation initiatives that will make Cochrane evidence available to many more people
around the world.
There are currently 14 Cochrane Centres, and, with the opening of this Caribbean Branch, 18 Branches.
Cochrane Centres coordinate, support, and promote Cochrane activity at a regional level. They act as a
main point of contact and information for a particular geographical or linguistic area; provide training
and support to Cochrane contributors and entities working in their area; and act as a liaison between
Cochrane and the local healthcare community. Cochrane Centres work to raise the profile of the
Collaboration to everyone involved in health care in their own region, from patients to clinicians to
researchers to policymakers, fostering a two-way dialogue that works to bring Cochrane evidence to the
healthcare community, and users and seekers of evidence into the ongoing work of the Collaboration.
Branches have a particularly important role to play in this organizational infrastructure. Most of the
Cochrane Centres are responsible for coordinating Cochrane activity across large and diverse areas, and
the specialized local knowledge that Branches can contribute is critical to building relationships and
identifying the specific information and support needs of a particular area. I hope that in the coming
years the new Caribbean branch will have a profound impact on regional health care by:

Disseminating Cochrane evidence and information across the region;

Improving practice and outcomes;

Building capacity to continue the work of generating and assessing evidence; and

Bringing this expanded Caribbean healthcare community into active membership within
Cochrane’s global network so that we can learn from each other.
I hope I have met my brief; and given you an insight on where The Cochrane Collaboration has come
from and where it is going. I am tremendously excited by the prospect that the new Caribbean branch
will be joining us on that journey. Our programme has on its cover a photograph of the statue which is
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on this University of West Indies campus, of the Savacou bird-god who controlled thunder and strong
winds. I was amazed to read that Archie Cochrane donated this statue and that a wonderful link has
already been established between us. But I am sure that Professor Cochrane would have approved when
I say that I hope that the vibrant work of this new Cochrane branch will become the most important, farreaching and influential Cochrane legacy in the university, in Jamaica, and across the region. I look
forward to working closely together with Damian, Marshall and all of your colleagues - and I look
forward to Savacou’s strong winds blowing The Cochrane Caribbean’s newest branch and the
organization as a whole to great future success.
Thank you!
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