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Following one of Cochrane's pathways

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    In 1978 this journal published an intriguing paper from Archibald L Cochrane. Under the ironic title of “Health service “input” and mortality “output” in developed countries” what they showed was an ecological association between number of doctors and...mortality. It has been one of the more quoted papers in the past 25 years and has been reprinted several times in readers of epidemiology, like the one edited by John Ashton on the epidemiological imagination. This paradoxical finding has been considered as an example of confounding in the epidemiological literature and an anomaly with unknown explanations. In this issue we publish a research report from Frank Young who seems to have added very convincing pieces of new insights to a definitive solution of the problem. Following the suggestion of Cochrane on the need to “extricate doctors from their unhappy position” Young has tested that expanding urban-industrial regions attract an oversupply of doctors. Also, but independently, rural people migrate to urban industrial areas where they suffer from the stress of adapting to a new life and an increase in their death rates.

    Controlling by this the association disappears, but still doctors are in an “unhappy position” in so far as Young has been unable to find positive associations between number of doctors and reduction of mortality. Both Frank Young and Selwyn St Leger, one of the coauthors of the 1978 Cochrane paper, compare in their papers these findings with the work of Thomas McKeown. The Role of Medicine, Dream, Mirage or Nemesis has been reinforced by the data we publish now. So it seems that much of the work of the greats of critical thinking in the 70s like McKeown, Cochrane and Ivan Illich remains essentially unrefuted. Another story is why, if essentially unrefuted, their ideas do not have more impact on health policies and practices.