Evidence Aid – from the Asian tsunami to the Wenchuan earthquake

On 26 December 2004, a powerful earthquake under the Indian Ocean triggered a tsunami that struck the coasts of many countries in the next few hours. At least 200,000 people were killed, more than two million were forced to move from their homes and the lives of millions more were affected (1). On 12 May 2008, an earthquake hit Wenchuan county in China, killing more than 70,000 people and injuring up to 400,000 (2). In the 1233 days between these two days, The Cochrane Collaboration had established the Evidence Aid project as a means of providing knowledge about interventions that might be beneficial, harmful, unproven, or in need of more research; and which might be relevant to people making decisions about health care in the aftermath of such natural disasters (http://www.evidenceaid.org) (3). This commentary discusses Evidence Aid, illustrating how the Collaboration's response to one event might have helped in the Chinese health system's response to another. A formal evaluation of Evidence Aid is currently underway and will report later this year. The Cochrane Collaboration is the world's largest organisation dedicated to the preparation and maintenance of systematic reviews of the effects of healthcare interventions, seeking to cover all areas of health (http://www.cochrane.org). It is a global effort, bringing together people from about a hundred countries to work on systematic reviews of research, to keep these up to date and to make them available in the Cochrane Database of Systematic Reviews (CDSR). This database is published in The Cochrane Library on CD-ROM and the internet (http://www.thecochranelibrary.com). In October 2008, CDSR contains the full text of more than 3500 Cochrane Reviews, with published protocols for a further 1900 reviews that had not yet synthesized the relevant research. During the year, 17,000 people were working within the 52 Cochrane Review Groups responsible for the preparation of these reviews (4), and the number of people in China continued to increase (5). At the end of 2004, there were 2200 full Cochrane Reviews. By May 2008, this had increased to 3300. However, someone searching CDSR to find systematic reviews of relevance to, for example, the treatment of crush injuries, the control of infectious diseases or the management of psychological trauma, would be faced with the difficulties of finding reviews of relevance within this large collection. They would encounter systematic reviews that are, at times, large and complex, providing a vast amount of knowledge, much of which might not be necessary for their immediate information needs. The wealth of information in full Cochrane Reviews should be relevant to people preparing plans for managing disasters of the future, but there is also a need for knowledge to be available in the aftermath of natural disasters and other large-scale healthcare emergencies. Evidence Aid seeks to bridge this gap by bringing together reliable and relevant information on the effects of healthcare interventions and making them available in a simple form, in a single place. It provides a resource for people making policy decisions about planning and providing health care in circumstances such as those faced after natural disasters or similar healthcare emergencies. In the days after the 2004 tsunami, members of The Cochrane Collaboration felt a moral imperative to help in the global relief and rehabilitation efforts. This was based on a compassionate response to tragedy in the lives of others and also on the recognition that efforts to help people recover require evidence on interventions that work and also on those that do not work. Delivering healthcare interventions that are not beneficial or, worse, harmful, would worsen the outcome for individuals and for societies. Reliable evidence on interventions to avoid is beneficial (6). The Cochrane Collaboration therefore took the decision to work with people in the affected region to develop a collection of resources, based principally on Cochrane Reviews, to summarize the evidence on relevant interventions. This collection would be made available to people who needed it free of charge through The Cochrane Collaboration's own website (http://www.evidenceaid.org). In 2007, there were 7100 visitors to this website, an average of 19 per day and the figure for the nine months to October 2008 is similar, with more than 4700 visitors to date. A working party was established in early January 2005 to organize the response. In consultation with all Cochrane entities and the 200 individuals listed as contributors to the work of The Cochrane Collaboration in the affected countries, a list of over 200 interventions considered relevant to health care in the aftermath of the tsunami was prepared. The specter of epidemics of infectious diseases dominated this initial list, which was categorized on the basis of whether there was an up-to-date Cochrane Review, a Cochrane Review existed but would need to be updated, or there was no Cochrane Review. This list was prioritized further in the subsequent months as the challenges shifted from the acute phases of a natural disaster to its medium- and long-term consequences, which are dominated by mental health. On 23 April 2005, the BMJ welcomed these efforts. Lynn Eaton wrote “People called in to help in health emergencies, such as the recent tsunami in Asia, will be able to get comprehensive up to date evidence based information, from a single source, on best treatments and approaches to handle such a crisis, thanks to the latest measures by The Cochrane Collaboration” (7). The main output of Evidence Aid is a collection of concise summaries of the findings of Cochrane Reviews. These are based on the series of Evidence Updates prepared by the Cochrane Infectious Diseases Group (http://www.liv.ac.uk/evidence/evidenceupdate/home.htm) for topics of high priority in low- and middle-income countries. The typical format for each Evidence Update is a two-page document. The document begins with a question and an answer summarizing the findings of the review. For example, “Are tissue adhesives better than sutures for closing traumatic lacerations?” with “Tissue adhesives yield similar cosmetic results, reduce procedure time and cause less pain than standard wound closure for simple traumatic lacerations, although the wound is more likely to re-open” (8, 9). This is followed by the inclusion criteria for the Cochrane Review, the results in both text format and as a single forest plot showing a key meta-analysis and the conclusions of the authors of the original review. A pdf file for each summary is available from the Evidence Aid website, which can be read, printed, and copied without payment. The summaries cover interventions relevant to infectious diseases, injuries and wounds, rebuilding of communities and infrastructure, mental health, nutrition, rehabilitation, and pregnancy and childbirth. If a summary has not been prepared but a relevant Cochrane Review is available, a link takes people to that review. An example of Evidence Aid drawing attention to a Cochrane Review of an intervention which, although well-meaning, is likely to do more harm than good concerns brief ‘debriefing’ to reduce immediate psychological distress (10). The rationale for this strategy is that it will prevent the subsequent development of psychological disorders, notably post-traumatic stress disorder (PTSD). However, the Cochrane Review shows that this strategy is unlikely to be helpful and may even cause an increase in PTSD in the medium- and long-terms. After the tsunami, many teams went to the Nagapattinam district in India which was one of the worst hit areas of Tamil Nadu, the state in India with the largest number of casualties. Teams offered forms of brief debriefing to survivors in each village before moving on to the next. The Cochrane Review was used to change this, as officials and nongovernment organizations were urged to desist from this practice (3). In early 2008, the summaries included two on the treatment of lacerations, two longer documents bringing together the findings of several Cochrane Reviews on the use of intravenous fluids and blood transfusion for trauma, four on the management of diarrhea, six relating to pregnancy and the care of newborn babies, fifteen for the treatment of infectious diseases (mainly malaria), and four dealing with depression and post-traumatic stress disorder. Summaries of four Cochrane Reviews relevant to the delivery of health services were also available. When the earthquake struck Wenchuan in May 2008, of the 200 interventions identified as relevant in the aftermath of the tsunami, approximately 70 had a summary within Evidence Aid, and there was an up-to-date Cochrane Review available for a further 30. This contrasts with the early months of 2005 when there was an up-to-date Cochrane Review for less than a quarter of the 200 interventions and specially prepared summaries were lacking for many of these. People responding to the health needs created by the Wenchuan earthquake were, therefore, able to be directed to Evidence Aid for some of the knowledge they needed. However, many challenges remain and an evaluation of Evidence Aid that had been started before the earthquake is set to provide some possible solutions later this year. There are challenges that arise from the usefulness of collections of evidence in the immediate aftermath of natural disasters. Even if this knowledge was accessible, the urgency of the relief efforts might mean that it is not accessed. Strategies are needed to ensure that it is used to guide the policies and plans that will be implemented after the disaster (11). There are large gaps in the availability of systematic reviews of relevant interventions, some of which will be filled by prioritization of these reviews but some of which might not be filled because of the difficulties of doing research and reviews for some of the complex questions that arise after natural disasters. And, even if a Cochrane Review or other systematic study has been done, it might not be able to guide practice due to a lack of relevant good-quality studies. In such circumstances, the most appropriate practice might be the conduct of new research guided by the findings of the review. Cochrane Reviews are rich sources of information on the types of new research that should be done to fill the gaps identified (12), and with appropriate prioritization, funding, and the willingness to conduct the necessary, pragmatic randomized, trials, these gaps will be filled. The best hope for a knowledge-based future arising from the wreckage of earthquakes and other natural disasters will be a cycle of systematic reviews, new trials, updated reviews, and targeting of the knowledge generated, so that it can help influence the many decisions that have to be made to improve health and speed recovery. The views expressed in this article are those of the author and are not necessarily the views of The Cochrane Collaboration.