After the war, Cochrane went on to have a distinguished career in medical research. This included studying pneumoconiosis in the coal miners of South Wales and becoming Professor of Tuberculosis and Chest Diseases at the Welsh National School of Medicine in 1960. As his career progressed, he became even more passionate about the value of evidence‑based medicine and the need to inform doctors about the most effective medicines. At the same time, he realized that doctors struggled to make sense of all the results from all the clinical trials that were being conducted around the world. Hence Cochrane argued that medical progress would be best served if an organization could be established with the responsibility of drawing clear‑cut conclusions from the myriad research projects. In 1979 he wrote, ‘It is surely a great criticism of our profession that we have not organised a critical summary, by speciality or subspeciality, adapted periodically, of all relevant randomised controlled trials.’
The key phrase in Cochrane’s statement was ‘a critical summary’, which implied that whoever was doing the summary ought to assess critically the value of each trial in order to determine to what extent it should contribute to the final conclusion about whether a particular therapy is effective for a particular condition. In other words, a carefully conducted trial with lots of patients should be taken seriously; a less carefully conducted trial with just a few patients should carry less weight; and a poorly conducted trial should be ignored completely. This type of approach would become known as a systematic review. It is a rigorous scientific evaluation of the clinical trials relating to a particular treatment, as opposed to the sort of reports that the WHO was publishing on acupuncture, which were little more than casual uncritical overviews.
An evidence‑based approach to medicine, as previously discussed, means looking at the scientific evidence from clinical trials and other sources in order to decide best medical practice. The systematic review is often the final stage of evidence‑based medicine, whereby a conclusion is drawn from all the available evidence. Archie Cochrane died in 1988, by which time the ideas of evidence‑based medicine and systematic reviews had taken hold in medicine, but it was not until 1993 that his vision was fully realized with the establishment of the Cochrane Collaboration. Today it consists of twelve centres around the world and over 10,000 health expert volunteers from over ninety countries, who trawl through clinical trials in order ‘to help people make well‑informed decisions by preparing, maintaining and promoting the accessibility of systematic reviews of the effects of interventions in all areas of health care’.
Having been in existence for over a decade, the Cochrane Collaboration has by now accumulated a library consisting of the results of thousands of trials and has published hundreds of systematic reviews. As well as providing judgements on the effectiveness of pharmaceutical drugs, these systematic reviews evaluate all sorts of other treatments, as well as preventative measures, the value of screening, and the impact of lifestyle and diet on health. In each case, the wholly independent Cochrane Collaboration presents its conclusions about the effectiveness of whatever is being systematically reviewed.
Hopefully this background to the Cochrane Collaboration has helped to convey its reputation for independence, rigour and quality. This means that we can now look at their systematic reviews of acupuncture and can confidently assume that their conclusions are very likely to be accurate. The Cochrane Collaboration has published several systematic reviews relating to the impact of acupuncture on a variety of conditions, focusing largely on the evidence from placebo‑controlled clinical trials.
First, here is the bad news for acupuncturists. The Cochrane reviews suggest that there is no significant evidence to show that acupuncture is an effective treatment for any of the following conditions: smoking addiction, cocaine dependence, induction of labour, Bell’s palsy, chronic asthma, stroke rehabilitation, breech presentation, depression, epilepsy, carpal tunnel syndrome, irritable bowel syndrome, schizophrenia, rheumatoid arthritis, insomnia, non‑specific back pain, lateral elbow pain, shoulder pain, soft tissue shoulder injury, morning sickness, egg collection, glaucoma, vascular dementia, period pains, whiplash injury and acute stroke. Having examined scores of clinical trials, the Cochrane reviews conclude that any perceived benefit from acupuncture for these conditions is merely a placebo effect. The summaries contain the following sorts of conclusions:
‘Acupuncture and related therapies do not appear to help smokers who are trying to quit.’
‘There is currently no evidence that auricular acupuncture is effective for the treatment of cocaine dependence.’
‘There is insufficient evidence describing the efficacy of acupuncture to induce labour.’
‘The current evidence does not support acupuncture as a treatment for epilepsy.’
Also, the Cochrane reviews regularly criticize the quality of the research conducted to date, with comments such as: ‘The quality of the included trials was inadequate to allow any conclusion.’ Whether the trials were reliable or unreliable, the upshot is the same: despite thousands of years of use in China and decades of scientific research from many countries, there is no sound evidence to support the use of acupuncture for any of the disorders named above.
This is particularly worrying in light of the sort of treatments currently being offered by many acupuncture clinics. For example, by searching for a UK acupuncturist on the web and clicking on the first advert, it was simple to find a central London clinic offering acupuncture for the treatment of all of the following conditions: addictions, anxiety, circulatory problems, depression, diabetes, facial rejuvenation, fatigue, gastrointestinal problems, hay fever, heart problems, high blood pressure, six categories of infertility, insomnia, kidney disorders, liver disease, menopausal problems, menstrual problems, pregnancy care, birth induction, morning sickness, breech presentation, respiratory conditions, rheumatism, sexual problems, sinus problems, skin problems, stress‑related illness, urinary problems and weight loss. These conditions fall into one of three categories:
1. Cochrane reviews deem that the evidence from clinical trials does not show acupuncture to be effective.
2. Cochrane reviews conclude that the clinical trials have been so poorly conducted that nothing can be said about the effectiveness of acupuncture with any confidence.
3. The research is so poor and so minimal that the Cochrane Collaboration has not even bothered conducting a systematic review.
Moreover, systematic reviews by other institutions and universities come to exactly the same sort of conclusions arrived at by the Cochrane Collaboration. Despite the fact that there is no reason to believe that it works for any of these conditions, except as a placebo, thousands of clinics in Europe and America are still willing to promote acupuncture for such a wide‑ranging list of ailments.
The good news for acupuncturists is that the Cochrane reviews have been more positive about acupuncture’s ability to treat other conditions. There have been cautiously optimistic Cochrane reviews on the treatment of pelvic and back pain during pregnancy, low back pain, headaches, post‑operative nausea and vomiting, chemotherapy‑induced nausea and vomiting, neck disorders and bedwetting. Aside from bedwetting, the only positive conclusions relate to acupuncture in dealing with some types of pain and nausea.
Although these particular Cochrane reviews are the most positive about acupuncture’s benefits, it is important to note that their support is only half‑hearted. For example, in the case of idiopathic headaches, namely those that occur for no known reason, the review states: ‘Overall, the existing evidence supports the value of acupuncture for the treatment of idiopathic headaches. However, the quality and amount of evidence are not fully convincing.’