Daly, J, <i>Evidence‐based Medicine and the Search for a Science of Clinical Care</i>

Daly, J. Evidence-based Medicine and the Search for a Science of Clinical Care , London , University of California Press and Milbank Memorial Fund, New York 2005 , £41.95 (hbk) 275pp . ISBN 0-520-24316-1 The annals of sociology are littered with turf wars, and few have been turfier or more warlike than reactions by social scientists to the claims of evidence-based medicine (or indeed evidence-based anything). In her survey of the pitch, Jeanne Daly, a South African sociologist and public health researcher now based in Australia gives an international perspective on the development of a science of clinical care. Her work is based primarily on a series of unstructured interviews undertaken sometimes on several occasions between 1989 and 2000 with key informants, supplemented by documentary sources. An introductory chapter explores certainty, uncertainty and the clinical task, the contested nature of ‘evidence’ in patient care, and the science underpinning different forms of knowledge. The starting point for almost any history of ideas is somewhat arbitrary, and frequently rests on the claims of particular proponents. Daly traces the intellectual heritage of evidence-based medicine starting with the development of clinical epidemiology in Schools of Public Health and Departments of Community Medicine (a discipline which has changed name more frequently than Sellafield) in North America and in particular at McMaster University in Canada. She goes on to look at the rise of evidence-based medicine – itself a contested term. One interview reveals that when he was to be knighted in 2001, the draft citation for lain Chalmers was to include ‘for services to evidence-based health care’. He asked for the words ‘evidence-based’ to be deleted, given his vision of evidence-based choice for consumers, rather than automaton-led healthcare. A chapter on appraisal and critique is not, as I had hoped, a critique based on the trenchant analysis Daly has demonstrated in her own work on public health research, but a top-dog-sniffs-top-dog appraisal of their own and others’ work by some of the leaders in the field. Moving onto the British intellectual heritage, Daly starts by describing the work of Archie Cochrane, Peter Elwood, Jerry Morris and Walter Holland. These four form part of a glittering array of top men in the field accorded their own sub-titles along with two top women, Suzanne Fletcher and Carol Joughin. A chapter on the genesis of the Cochrane Collaboration follows, including an interview and other data demonstrating the towering (and touchingly modest) contribution of Iain Chalmers – undoubtedly the founding father and, throughout his research career, a contract researcher. The part played by the combination of volunteerism and the NHS R&D programme in the UK, under the leadership of Michael Peckham, which got Cochrane (and the NHS Centre for Reviews and Dissemination) off to such a good start, are described. A chapter on the Cochrane Collaboration in South Africa has a rivetting analysis of the politics of evidence and AIDS and the book concludes with chapters on the achievements (seen as including transparency, democratic debate and a collegiate way of doing business) and limitations (seen as including a lack of attention to implementation). What has the book to offer to the sociologist? David Armstrong's views are described in brief, suggesting the rise of ‘scientism’, the creation of a new elite and source of authority, and the undermining of individual clinical freedom. The claims made by both the clinical freedom artistes, and the Cochranoids are not, of course, necessarily in total opposition unless you are one of the intellectual gladiators. Informed users of health services, whether they are practitioners or patients, are less likely to be at the mercy of an all-knowing but secretive elite. There is a tantalisingly brief discussion of the role of charismatic leadership, a reference to ‘great men’ theories but without the accompanying analysis of the absence of women. Were they in fact absent, or were they simply hidden from history through the bias inherent in selecting interviewees on the basis of repeated references in the literature and names that came up in the course of interviews? At least two women sociologists in the UK (who merit passing reference but no more in the book) – Ann Oakley and Jennie Popay – have played sustained and constructively critical roles in evidence-based medicine from the outside of the clin-epi tent. Inevitably for a book which was a long time in gestation, with the first interview in 1989 and the last in 2000, some wicked problems have moved on (if only by a few millimetres). The hierarchy of evidence to which Daly refers has been largely discredited and is rarely used other than to prop up straw men. There is a much greater openness to methodological diversity in EBM, (due in no small part to the missing women). These are areas to which Daly is well-placed to turn her attention next, but meanwhile, for anyone with a curiosity about the inside track in evidence-based medicine, this book is destined to become a classic in its history.

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