Equality, efficiency and effectiveness: going beyond RCTs in A. L. Cochrane's vision of health care.

A. L. Cochrane's Effectiveness and Efficiency frequently appears as a key reference in debates over, and a justification for, contemporary evidence-based medicine. Cochrane's concern in this text with the equality of care as the ultimate rationale for why effectiveness and efficiency of cure are needed has, however, largely disappeared from debate. In this article, we reconsider Cochrane's approach through the use of case studies of plural forms of medicine in the Czech Republic, namely traditional Chinese medicine, homeopathy and spa care. In addition to bringing equality back into the picture, we also identify four expansions to Cochrane's original vision arising from the difficulties of separating cure from care; the overlap between prevention and cure; the complex actions of some multi-faceted therapies; and recent reconceptualisations of the placebo effect. In conclusion, we suggest that instead of the widely used strictly vertical "evidence pyramid", a descriptor of the horizontal and additive ordering of evidence might be more appropriate. We also argue that in healthcare systems characterised by a multiplicity of approaches, if we want to truly benefit from this heterogeneity, we must take seriously each medical tradition's approaches to prevention, cure, care, as well as efficiency, efficacy and equality.