|In 2010 Sir Iain Chalmers, distinguished medical expert from UK, was a guest of the School of Medicine of the University of Split, Croatia. On this occasion he gave an interesting interview dealing with his contacts with Croatian scientists, Croatian Medical Journal, and his rich medical experience. He practised as a clinician for seven years in the UK and the Gaza Strip, and then became a full time health services researcher.|
Iain Chalmers qualified in medicine in the mid-1960s. He practised as a clinician for seven years in the UK and the Gaza Strip, and then became a full time health services researcher with a particular interest in assessing the effects of health care. Between 1978 and 1992 he was founding director of the National Perinatal Epidemiology Unit (www.npeu.ox.ac.uk). Between 1992 and 2002 he was founding director of the UK Cochrane Centre, which convened the meeting that inaugurated the Cochrane Collaboration (www.cochrane.org), a not-for-profit, international organization that prepares, maintains and publishes systematic reviews of the effects of health care interventions. Since 2003, Iain Chalmers has coordinated the James Lind Initiative to promote public and professional acknowledgement of uncertainties about the effects of healthcare interventions, and research to address these uncertainties. The principal components of the James Lind Initiative are The James Lind Library (www.jameslindlibrary.org), which explains and illustrates the rationale for and characteristics of fair tests of healthcare interventions; the UK Database of Uncertainties about the Effects of Treatments (UK DUETs) (www.library.nhs.uk/duets); and the James Lind Alliance (www.lindalliance.org), which promotes research priority setting partnerships of patients, carers and clinicians. Iain Chalmers was knighted for services to healthcare in 2000.
Interview with Sir Iain Chalmers at the School of Medicine of the University of Split, Croatia
INTERVIEW WITH SIR IAIN CHALMERS
by Dr. Irena Zakarija Grković, University of Split
Irena: Dr Chalmers, it’s an honour to have you here in Split amongst us. We know that you founded the National Perinatal Epidemiology Unit in the UK which was one of the steps towards establishing the UK Cochrane Centre of which you were the founding director for 10 years. Can you tell us something about that?
Iain Chalmers: It was my experience both as a medical student and as a doctor, to be confronted with different specialists having different opinions about how to treat the same condition. For example, when I was at medical school, there were a few doctors who were saying that radical mastectomy was not necessary as a surgical treatment for breast cancer. Other doctors, other surgeons were saying it should be routine. When I went to exams I had to remember what that particular specialist who was conducting the exam thought what the right treatment is. The other thing was, at medical school we weren’t encouraged to challenge our teachers to show us the evidence upon which their statements of treatments were made-either they were useless or useful. This came to me particularly vividly when I was working for the UN in the Gaza strip when I found that some of the things that I had been taught at medical school were resulting in the suffering and deaths of my patients. So from that moment on I became rather obsessional about evidence as opposed to authority in deciding about treatment. Another example was a book by an American paediatrician, Dr Spock- a very, very famous book; when I got my copy in 1965 it had sold 19 million copies. In this baby and childcare book, dr. Spock advised that babies should be put to sleep on their tummies from as early as possible. We now know, in retrospect, that his advice which was not based on evidence but on a theory resulted in at least ten thousand sudden infant deaths, in the UK alone. Such things led me to, first of all, learning how treatments are evaluated in a valid way and then after specialising in obstetrics and gynaecology, to try to assemble evidence in that field which would guide the decisions by women, obstetricians and midwives for care during pregnancy and childbirth and in the time following childbirth. Because people were interested in my initial work in that field, they asked if I could try to establish a National Perinatal Epidemiology Unit. We did a very thorough review of all the controlled trials that had been done and published in pregnancy and childbirth and we published that not only in a very big book-two volumes, 1500 pages-but also a summary paperback for women so that they could have the benefit of the results of the research. We also started publishing electronically in 1988. so that the analyses that we had used for the textbooks would be updated as new evidence became available or as we identified mistakes that we had made in the earlier reviews. That model of electronically published systematic reviews of studies looking at the interventions in pregnancy was the pilot project of the Cochrane Collaboration which was started in the early ‘90s. What was called the Cochrane Centre in 1992 became the UK Cochrane Centre in 1993 because the Cochrane Collaboration which is an international organisation, which now involves some 30 thousand contributors from all over the world, including some from Croatia I’m glad to say, and in trying to help doctors and other clinicians avoid make mistakes and to try and make that information freely available to them and to patients.
Irena: Can you clarify for our readers what is meant by a ‘systematic review’?
Iain Chalmers: Usual way of writing books is as far away from an organised scientific investigation. One can understand how all sorts of biases can get in, by people missing out important information, by adding their own biases and prejudices for treatments. A systematic review is basically an attempt to address that type of anarchy by writing a protocol for a scientific study which implies that you need to identify the question that you’re going to address. You then identify the type of materials that are going to be relevant to the question. You then work out how you’re going to apply the eligibility for including or excluding studies for those that you find which means you got to have search strategies that should be performed by a skilled librarian. Librarians are very, very crucial in doing this. You then have to extract the data that you find in the published reports in a way which minimises bias; you then have to ask the question ‘are there other studies relevant to my question that haven’t been published and how can I find those?’ or indeed within the studies that you have found you have to ask the question is there evidence that they haven’t published which is relevant to the assessment of my study. You then have to ask whether statistical methods are appropriate, sometimes they aren’t at all, sometimes they’re very important, sometimes it’s both possible and appropriate to do something which is called a metaanalysis and that means taking a group of similar studies, obtaining the statistics of each of those studies and from those studies, each of those statistics generating an overall statistic which describes the finding in that body of evidence. And then you have to write your conclusion as you do in a usual study and you need to write them in a way that is faithful to what the data show and not what you would like them to show.
Irena: So does that mean that literature reviews are obsolete?
Iain Chalmers: It depends on what you mean by a literature review. If you’re saying ˝does that mean you can forget about unpublished studies˝ because literature implies that they’re actually in the literature, then no, you can’t forget about unpublished studies. You have to look hard for them because we know that there is so called ‘publication bias’, ie, if a research study yields a result which disappoints the researchers too often they don’t submit it for publication. Or even if they do submit it for publication, the editors of the journals may find them disappointing too and may not publish them. So, the idea of a literature review depends on what type of question you’re trying to address and what methods are appropriate for addressing that question. For example, of you wanted to do a literature review on treatment of the common cold then the best way to go about that would be to find a systematic review of all of the studies that relate to the etiology of the common cold, all of the studies that look at prognosis, all of the studies that look at diagnosis assembled in systematic reviews, all of the studies that have looked at treatments of various kinds (vitamin C, Echinacea, antibiotics..) and then you could take an overview of all those systematic reviews and it could be a very helpful thing for people who want to know how to identify and manage a common cold which, as some person said, if you take treatment it gets better in seven days, if you leave it to itself, it better in a week...
Irena: Since 2003 you have dedicated your energy to a new project ‘The James Lind Initiative’. Can you tell us what it’s about?
Iain Chalmers: What we found increasingly in doing systematic reviews of the literature is that the questions which the researchers have addressed had tended to ignore the questions that patients and clinicians think are important. One way or the other the public, in essence, pays all research, so the public, I think, deserves to have more of a say in what gets researched and what doesn’t. I’ll give you one example which illustrates the problem. If you take osteoarthritis of the knee, researchers asked four different focus groups what type of research they would like to see done to improve the lives of people with osteoarthritis of the knee - patients, rheumatologists, general practitioner and physiotherapists. Maybe about ten people in each of those groups. None of them wanted any more drug research. What they wanted was more research on education and management strategies or how to handle this disabling and painful condition. The physiotherapists wanted funds to do better physiotherapy research because they felt that physiotherapy might be helpful but it was important to find out in what circumstances it would be helpful and physiotherapy research is very difficult to do. By comparison, good physiotherapy research is much more difficult to do than good drug research. But then when you looked at the research that researchers were actually doing, it was almost all on drugs. So it was almost a complete mismatch between what patients and clinicians wanted to see and what researchers were doing. Researchers were doing these studies for example because industry has an interest in drugs and can pay for trials to be done usually for another unnecessary non-steroidal anti-inflammatory drug to try and tap that big market for pain relieving drugs. So, we established a UK database of uncertainties of the effects of treatments. In other words, these were questions that could not be answered either by an up-to-date systematic review of the relevant evidence, either because a review hadn’t been done or there were reviews there but they were not up-to-date or reliable, or an up-to-date, reliable systematic review had shown that no one knew the answer to the question. Then, at the James Lind Alliance, some very skilled facilitators got patients and clinicians to discuss together, using a formal process, which of the uncertainties that had been identified should receive priority for either new systematic reviews or updates or new research. They then lobbied our research funders in the UK to get those questions addressed and funded. The main thing is to bridge this gap between what the research community is doing and what patients and clinicians would like them to study.
Irena: What would you tell our ministers for education, science and health? What would be your recommendations how to go about doing this?
Iain Chalmers: The first principle that I would want them to impose is that no new research should be funded until people are clear about what existing evidence shows! Thus, there should be no funding research projects without performing systematic reviews of the existing evidence. The implication is that there should be funding for systematic reviews. If you ask a lay person, who doesn’t know anything about academia, whether that would be a good idea, they’re very surprised that it hasn’t been done already. The next thing the authorities need to think about is what are the opportunity costs of allowing industry’s agenda to dominate the research agenda, when in fact that may exclude unanswered questions about the existing treatments that are important to patients. Examplea can be drugs that have been in use for a long time, or talking therapies such as psychotherapy, or interventions to support women who want to breastfeed. Those don’t have any commercial interest but they can be very important questions so unless government and charities support research addressing those important questions, which are of no interest to industry, they won’t get addressed and will remain ignorant about things which are either killing patients, and have been for decades, or things that can be very beneficial to patients but haven’t attracted any industry interest.
Irena: You’ve had the opportunity to witness this first hand in the Gaza Strip where you spent some time working as a doctor and have been returning there ever since. What prompted you in the first place to choose to go there and how can we, as academics, help those in need?
Iain Chalmers: I was reading about the history of that part of the world and I realised what a disgraceful role my country, the UK, had played and where, in essence, we were still suffering from the chaos we caused by dividing up the middle east with the French during the First World War and we promised the same bit of land, that didn’t belong to us, to two different national movements: the Zionist National Movement and the Palestinian National Movement. That was bound to end in the sort of problems that we continue to see. So, I decided to go and work there out of a feeling of shame in fact. I went to work with the UN because I believe that the United Nations is important. I believe that the Universal Declaration of Human Rights is a very important document and that international law is an extremely important basis for trying to secure justice and peace in the world. If any doctor thinks that they shouldn’t be into politics it is nonsense because even if they don’t become actively involved they’re acquiescing in the situation around them. So they’re involved by not being involved.
Irena: We started with Gaza so I’d like to conclude with whether you see any likely resolution to the conflict in the Middle East?
Iain Chalmers: There is an oppressed people and an oppressor people. So the first situation one has to confront is ‘do I have any responsibility to support the oppressed people?’ Palestinians are stateless-they have been occupied longer than any other population in modern history. Croatia, in particular, should be sensitive to the feeling of disenfranchisement during occupation because Croatia has experienced centuries of occupation. So the issue is that, in the land of Palestine, between the Jordan River and the sea, there are approximately the same number of Jews and non-Jews, but in essence it’s all controlled by the Jewish State, and is self defined as the Jewish State. It is seen as the state of all Jews everywhere in the world. So basically you’ve got a situation of apartheid at the moment, enshrined in Israeli state law. Some laws actively discriminate against non-Jews. So either there will be ongoing apartheid or there may be massacres or big displacements. We’re talking about six million non-Jews-it’s an awful lot of people to get rid of in what many Israelis see as their state form the river to the sea. Or circumstances could evolve such that either a bi-national state or a single state could emerge with equal rights for all its citizens which would inevitably mean the end of a Jewish state which gives special privileges to Jews and denies these to non-Jews. I just can’t see the situation that’s there at the moment lasting forever given the countries that are roundabout- it’s inconceivable to me that it will last forever. But how it will change I don’t know.
Irena: Well, let’s hope they choose the latter option...
Iain Chalmers: That would be very good. It’s difficult to see any consensus within Israel. I would like to see some solution preferably without any bloodshed but while we, the international community, allow international law to be flouted and the fourth Geneva Convention to be ignored, we’re actually contributing to the lack of resolution. I’ll go back to what I said earlier, if this world is going to be a world worth living in, there has to be respect for international law. Now, that may be a tedious and longwinded way around but anything else becomes dictatorship, unacceptable double standards, basically other situations which are just not acceptable to people who I believe should have the interests of their fellow human beings in mind.
Formated for CROWN by prof.dr. Darko Žubrinić
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