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Evidence of the people, by the people, and for the people

Prathap Tharyan
Editorial Article

At the recently concluded Colloquium of the Cochrane and Campbell Collaborations, The Cochrane Collaboration announced that from October 2010, 500 million internet users living in 42 countries with a gross national per capita income of US$ 1250–US$ 3500 will have free direct access to the resources in The Cochrane Library. This initiative is an expansion of the policy introduced in 2007 allowing free one-click access to The Cochrane Library in 67 countries with a gross national income per capita of less than US$ 1250 (those in the World Bank list of lowest-income economies). This initiative saw the use of Cochrane Reviews increase six-fold in these countries in the following two years [1]. The further expansion means that people in 109 countries in some of the most impoverished parts of the world will have free access to reliable evidence regarding their healthcare needs.

The announcement was made during a plenary session at the Colloquium in Keystone, Colorado, USA, which focused on using evidence to deal with emergent global issues. In this session I made reference to the Gettysburg address; but what does Abraham Lincoln’s short but influential and widely quoted speech (delivered a few months after the decisive battle of Gettysburg of 1863, during the American Civil War) have in common with The Cochrane Collaboration or The Cochrane Library? The iconic speech pronounced that the founding principle enshrined in the Declaration of Independence – that "all men are created equal" – was worth fighting for, and that "government of the people, by the people, for the people, shall not perish from the earth" [2]. Just as participatory democracy faces the challenge of ensuring inclusiveness, The Cochrane Collaboration faces the challenge of ensuring that this evidence is accessible to all people, particularly those living in low-income countries with a disproportionate burden of disease and who are most in need of this evidence, yet who have competing priorities for their limited resources.

In addition to low-income countries granted free access to The Cochrane Library (including free access for a limited period in Pakistan, following the recent floods, and in countries affected by recent earthquakes and the 2004 Asian tsunami), a number of middle- and high-income countries have provisions funded by governments or other agencies that ensure that all their residents have free access to reliable evidence. These investments are examples of responsible leadership in health care. However, there are many other regions of the world that are not covered by any of these initiatives, where barriers to access include the absence of local-language translations of relevant portions of Cochrane Reviews and other resources.

The reference to Lincoln's speech in the plenary session also attempted to demonstrate that the principles underpinning the efforts of The Cochrane Collaboration in preparing, maintaining and disseminating reliable, independent, and up-to-date evidence on the effects of interventions in health care follow the same lofty goals enumerated by Abraham Lincoln for participatory governance. The Cochrane Collaboration’s founding principles include collaboration and teamwork; building on the enthusiasm of others by involving and supporting people of different skills and backgrounds; striving for relevance by encouraging the evaluation of the efficacy and safety of interventions; using outcomes deemed important by people making choices about their health care; encouraging diversity; and reducing barriers to wide participation. The 4000+ systematic reviews in The Cochrane Library are prepared by more than 28,000 volunteers, who increasingly come from low- and middle-income countries. The entities in The Cochrane Collaboration include a growing number of healthcare consumers who provide training to other consumers in framing questions that research can answer, and who offer a consumer perspective on the relevance of review questions, choice of outcomes, balance of benefits and harms, and who help prepare simple summaries of the key messages in the reviews. The Cochrane Library now also includes special collections of systematic reviews on the effectiveness of interventions following major disasters, to guide effective planning and delivery of health care through the recent Evidence Aid initiative (Tharyan 2005). Evidence in The Cochrane Library can be thus considered to be of the people, by the people, and for the people.

Martin Luther King, Jr also referenced the Gettysburg address in his "I have a dream" speech at the Washington DC Civil Rights March [3]. The Cochrane Collaboration started as a dream and is now a vibrant testament that with collaborative partnerships, rigorous scientific methods and a principled approach, evidence of, for, and by the people can indeed be a reality.