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Gøtzsche and the Cochrane Collaboration: A Timeline

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Introduction

An awful lot has been said and written about the conflict between Peter Gøtzsche and the Cochrane Collaboration – including by me. The final dramatic breakdown in September 2018 provided an opportunity to raise all sorts of grievances and issues people had – with the organization, individual protagonists, and/or evidence-based medicine (EBM). 

It was confusing, and like others, I was making my mind up about things quickly in a heated controversy. In the aftermath, I wanted to give this more un-pressured consideration, and be confident about historical accuracy. I was being very critical of Gøtzsche publicly, and felt a responsibility to be sure my position was justified, or course correct if it wasn’t. To look at the evidence trail systematically, I constructed a timeline of the relationship from its beginning, to try to get a perspective of what happened, and decide what was critical. I thought the timeline and the conclusions I drew from it might be helpful to others, so I posted it (in the days after Gøtzsche published his book on vaccines).

The timeline describes key developments and actions that I think propelled Cochrane and Gøtzsche along this path, including relevant context. I have tried to be fair in several ways, with enough detail and sources to enable people to follow the trails of different interpretations and narratives at points along the way. And later there is a collection of links to places where the protagonists speak for themselves, and to viewpoints by others who come to different conclusions than I do. (There are links to all my related published writing as well.)

Gøtzsche posted many documents online at his personal website, often confidential ones that he has released without permission of those involved. That poses ethical dilemmas. I decided to read it all, and I bought a couple of his books that I needed to try to understand his point of view about what he considered key events. However, I don’t want to add to the damage done by publication of personal correspondence, confidential papers, and serious unsubstantiated allegations and character slurs from Gøtzsche, so I rely as much as possible on other public records to support the statements in this timeline. On a few occasions, where I had no other option and thought it was too important to leave out, I note the source without linking to it: those are references [in square brackets].

First, some context that I think is critical to understanding the Cochrane/Gøtzsche relationship. When we formed the Cochrane Collaboration (CC), we established various types of structures. Cochrane review groups were the editorial groups responsible for producing Cochrane reviews, for example – you can think of Cochrane’s journal really as 53 separate subject journals, sharing some methods, software, and a publishing platform.

Another structure was “Cochrane Centres”. Gøtzsche was the director of one: the Nordic Cochrane Centre (NCC). Centres had a dual role. One was a training and support service function for individuals and Cochrane groups in their geographic region. The other was “outreach”. A Cochrane Centre was a base to promote systematic reviews in health care, and recruit people and resources to the cause.

The Centres had the Cochrane name and right to use the logo, but they functioned autonomously. They were expected to make a contribution of some kind to the organization centrally. For example, when I worked at the Australasian Cochrane Centre in the early days, I produced Cochrane News, the organization’s international newsletter, and the local Cochrane Centre Director raised the money to pay me to do it, and to print and mail the thing out. There weren’t many Cochrane Centres for most of the organization’s life: only 14 in 2014.

There wasn’t a term limit for a Centre, or for being one’s director. Several previously little-known people achieved positions of power and influence, especially locally, from being Centre directors. The Centres have been self-governing principalities with their own agendas, but they are often seen from the outside as branches of the organization. They weren’t in the usual sense, though. They had a lot of influence on the Collaboration, including its governance, but there wasn’t much influence in the other direction.

As you would expect from such a loose arrangement, Centres and their directors developed very differently. Some have never really had much funding; others have had a lot. The directors and Centre staff caucus, having had separate meetings since soon after the organization began. Centre staff members are a tiny minority of the Collaboration, which had 17,000 full members and 37,000 supporters in 2018. 

However, people employed at Centres are one of the biggest cadres of people employed full-time in the Cochrane world, with lots of people therefore able to devote single-minded attention to things Cochrane. That resource also brings in perspectives from different parts of the world. But it is a big problem if the power and role of Centre directors is being considered. At the time of Gøtzsche’s expulsion, people from Cochrane Centres held 5 of the 13 seats on Cochrane’s board.

Disclosures: Like Gøtzsche, I am one of the co-founders of the Cochrane Collaboration. My relationship with the organization first fractured over the issue of independent consumer advocacy, and we eventually parted ways in 2012/2013 when Cochrane decided not to negotiate an alternative funding path that would have enabled fully open access to Cochrane reviews and the trials register. I have not been a member of the organization since, although I participate in some activities. For example, I am currently participating in discussions and planning about a Cochrane review of which I have been critical. I have recently written both critical and supportive pieces about the organization and specific Cochrane reviews. I have collaborated with Peter Gøtzsche (last in 2013), and I have had agreements and conflicts with him. Previous further disclosures are at my PLOS Blog.

Hilda Bastian

8 February 2020

[List of what I've written updated on 28 February 2020, when a journal published a commentary they invited from me to accompany the systematic review on HPV vaccines co-authored by Gøtzsche.]

 

 


Key events and context timeline

 

1993

Both the Cochrane Collaboration (CC) and the Nordic Cochrane Centre (NCC) were established, with Gøtzsche on the CC governing board (then called the Steering Group), and as Director of the NCC. (Disclosure: I was also on the first Steering Group.)

 

1996

Responsibility for the central function of software development for information management for Cochrane reviews transferred from the UK Cochrane Centre to NCC when the project leader moved from Oxford to Copenhagen.

>> 

Gøtzsche's term of office on the Steering Group ended.

 

1999

Gøtzsche was struggling to find financial support for the NCC, and informed the Danish government that if they did not provide secure ongoing public funding, key personnel would have to be lost, and he himself might “go back to internal medicine”. (He had stopped clinical work in 1997.) That funding took a while to arrive, but it came. (Source)

 

2001

Gøtzsche said that was the year he had his first conflict with CC leadership. It was about a manuscript of which he was a co-author, criticizing the quality of Cochrane reviews, which was to be published in the BMJ.

Gøtzsche speaks of facing an aggressive “tribunal” of three people. Whoever that was, it was not official. You can see the minutes of the meeting where Gøtzsche and one other co-author of that study met with 14 people at the meeting of the Steering Group. Disclosure: I was there. My recollection is that Gøtzsche was being reasonable, some were over-sensitive about criticism, but it seemed to be resolved collegially. The minutes record: “All members of the Steering Group supported the principle that the authors of the paper were of [sic] freedom to express their views in public and the Steering Group did not wish to censure that”, but asked that the paper also discuss the organization’s efforts to improve quality.

>>

Later that year, a bruising battle for all the involved parties began over Olsen and Gøtzsche’s mammography review. They had published a review in The Lancet in 2000, and were negotiating the contents of a Cochrane review on the subject. It was a tough situation. The Cochrane Breast Cancer Group was working with the authors through a minefield of issues and conflicting views. Gøtzsche had been active in the media on the issue for some time by then, and facing a barrage of vitriol from the screening world. This environment, with authors having already taken a public position in such a torrid conflict, made it difficult to deal with scientific disagreements in the editorial process. Alessandro Liberati was one of the Breast Cancer Group editors: “’We are in a situation of scientific controversy, with different interpretations of the same dataset’, Professor Liberati explained”. (Disclosure: I was one of the people who disagreed with some of Olsen and Gøtzsche’s analysis and interpretation ­– it’s one of the times Gøtzsche and I butted heads.)

When a compromise position was reached to release a partial version of the review, Gøtzsche negotiated with The Lancet to release his preferred version of the full review as a fast track research letter, on the same day as the Cochrane review would be published (without letting Cochrane know there would be a simultaneous publication). The Lancet version came with an editorial putting the CC on blast for censorship.

Peter Langhorne, then Chair of CC, replied: “...Cochrane reviews probably require more negotiation and revision than conventional publications for two reasons. First, Cochrane editorial groups are committed to try to publish reviews – rejection is very much a last resort. Second, because limited resources must be used responsibly there should only be one Cochrane review addressing a particular question. It therefore needs to be comprehensive and balanced. I recognise that negotiations within the constraints imposed by accepting these principles could raise the suspicion of censorship, but at least the process is transparent. By contrast, traditional journals have certainly exercised what amounts to editorial censorship by simply rejecting reports. Dispute will inevitably arise sometimes between Cochrane review researchers and editors…Ultimately, if researchers are unhappy with the process, they are free to withdraw their review”.

As a non-academic watching struggles like this one, it was striking which aspects of the Cochrane Collaboration were hard for academics to adjust to. Collaborative editorship was one (along with publishing protocols first, and authors with different views being urged to collaborate on one review jointly). That there were so many differences in how individual editorial groups went about their roles exacerbated dissatisfactions, too. You could sail quickly through one group with little input and standardization of methodology, and face intensive demands from another. (Disclosure: I was the coordinating (“lead”) editor of another Cochrane editorial group around then.)

There was CC concern over Gøtzsche leaning on the Cochrane name for the non-Cochrane version of the mammography review. Gøtzsche’s take on this: “I admit we gave our research letter [in The Lancet] a journalistic title, an appetizer, as people had been awaiting our Cochrane review for so long: ‘Cochrane review on screening for breast cancer with mammography’. But this was followed by a small summary that made it clear that the research letter wasn’t the Cochrane review…”.

Negotiations over the full Cochrane review would drag on painfully for all sides: it was published in 2006.

 

2002

NCC listed the CC as a funder for the first time. The CC was partly funding the software/information management development at the NCC. CC reported overall amounts for maintenance of the information management and some special projects, but it’s not clear to me what the annual amounts to the NCC were. NCC reporting about its funding was always limited to the names of funders. The CC provides detailed accountant reports as required for UK charities and they are online.

 

2003

This is the year Cochrane's leaders said the earliest recorded conflict between Gøtzsche and the central organization occurred. It was about multiple incidents of publishing material seen as harming the CC and causing conflict with colleagues: he was seen as using his NCC status to pursue his own interests. Gøtzsche argued that his activities benefited the NCC and the CC. [3]

 

2008

The first editor-in-chief for The Cochrane Library (which includes the Cochrane reviews) was appointed.

>> 

A major strategic review of the Cochrane Collaboration began, with management consultants, including among its areas of focus, “brand and glue”, and “financial viability”, reflecting the already deeply ingrained business ethos of the organization.

>> 

The NCC requested a substantial increase in funds for information management system development. If I understand that budget bid correctly, the recurring running costs (without special projects) provided by the CC was close to US$0.5 million annually at the time. The board then approved what appears to be an additional US$260,000 in projects, and an extra full-time position. (April 2009 governing board minutes.)

 

2009

The strategic review made 26 recommendations, all of which were accepted by the Cochrane board. (April 2009 meeting.) As well as solidifying Cochrane’s business model and trajectory for the long term, accountability was a theme. One of the recommendations was to review the terms of reference of Cochrane’s entities (the collective name for all the groups, centres, etc). From that report: “The majority of respondents argued for greater accountability of the entities and leadership in The Cochrane Collaboration. One respondent commented, ‘It’s bizarre that the Collaboration does not hold its entity leaders to account’. Two of the related recommendations were:

“We recommend that the Collaboration should develop and implement performance appraisal mechanisms for entity leaders…We recommend that the Collaboration should enhance accountability mechanisms of entities to ensure core functions are met and Collaboration policies are implemented”.

One of the report’s 5 overarching themes was listed as management, accountability and effective leadership: “Perceived variations in the quality of our product and processes and failure of accountability within the Collaboration were common concerns raised throughout the review process that were considered a potential threat. The Collaboration appears ready to improve its management structures, promote and support effective leadership and enhance the accountability of entity leaders and members”.

A re-organization of governance structure was also recommended, including a recommendation to move away from entity membership to individual membership.

 

2011

Both sides still weren’t specifically reporting the amount of funding from CC to NCC, but the 2011-2012 annual CC report has line item expenditure over US$0.5 million for information management system running costs that year: whether there was project funding as well isn’t clear. Team leadership was still at the NCC. (Source)

 

2012

Gøtzsche's book about his battles over mammography was published.

>>  

In November, Mark Wilson became the CEO of CC. One of his goals, he said, was “strengthening the organisation’s central infrastructure”. A few months later, the Chair of CC said of the remit they gave the new CEO: “We needed someone to provide a strong, enabling infrastructure that will support our 28 000 people around the world” (in a 2013 report in the Canadian Medical Association's journal). “Organizationally, Cochrane realized after 20 years they need to professionalize as a major international organization,” says Wilson. “We are a vast organization, still being managed in an ad hoc hand-to-mouth sort of way. To be ready for the next 20 years, we need to be transformed.”

 

2013

Gøtzsche began to publish solo author forms of research that would appear only in his books. Later, he would explain why he preferred that to submitting his work to peer-reviewed journals: “… I love nowadays publishing books – because people don’t interfere with what I want to write. It’s gorgeous!” These books were for sale for personal profit, and became his references for multiple evidence claims. In turn, he would promote those books via the media and in media interviews, with the Cochrane name conferring scientific legitimacy.

The books provide insight into his worldview and advocacy/rhetorical style, as well as his approach to evidence when it’s unfiltered by contributions of co-authors and scientific editors. In his 2013 book, he used the language of organized crime to describe the pharmaceutical industry, and allegations of crime begin to feature more in his rhetoric generally from here on. The book reportedly has “whore doctors” as an indexing term. It is called Deadly Medicines and Organized Crime, and it was promoted as an NCC product, for example, in the NCC annual report: “…we published a book in 2013 that details the many flaws in drug trials and the pervasive criminal activities, both in research and marketing, in the drug industry, "Deadly medicines and organised crime: How big pharma has corrupted health care".

 

2014

Gøtzsche published an article in January in a major Danish broadsheet, Politiken, called “Psychiatry gone astray”, beginning, “At the Nordic Cochrane Centre we have researched antidepressants…” He went on to criticize the basis and content of psychiatric care generally, with claims such as that antidepressants cause bipolar disorder, and conclusions like “Our citizens would be far better off if we removed all the psychotropic drugs from the market, as doctors are unable to handle them. It is inescapable that their availability creates more harm than good”. (Source: At Politiken, Gøtzsche's translation quoted above.)

The Minister of Health, the National Board of Health, and more protested about the incendiary conclusions. In March, the Danish Psychiatry Society contacted the Cochrane review groups in mental health, asking for their evaluation about the claims made in Gøtzsche’s January article. CC leaders responded to the Society that Gøtzsche was not speaking on behalf of the organization, the views were his own personal ones and they were not supported by the organization. The CC spokespeople wrote that they supported and respected Gøtzsche, but they had also asked him to make it clear in future when he was repeating claims from his book and personal research that these were his views, and not use the Cochrane name. (Source)

Cochrane distancing itself from Gøtzsche’s views soon became the story in another Danish newspaper. Gøtzsche later wrote that “The letter from Cochrane’s leadership was a threat to what I had built up over 30 years, including my centre, which is on government funding”.

In response to CC concerns, Gøtzsche removed the link advertising his book for sale from the NCC website, and agreed to separate his promotion of personal opinions from his role in CC/NCC. [3] The board decided to develop a formal spokesperson policy. [3]

>>

Gøtzsche was invited to play a kind of “deep throat” about the pharmaceutical industry on The Daily Show with Jon Stewart.

>>

That year’s NCC annual report was the last one that listed CC as a funder of the NCC. (Gøtzsche later reported that 8 members of NCC staff were, around then, on the information management team.)

 

2015

Gøtzsche participated in a debate in London on whether long-term use of psychiatric medicines does more harm than good, arguing in favor of that motion. The BMJ published short papers by the participants where they argued their case. These were released to the media on 9 May, with an embargo. Gøtzsche sent a copy of his to the CC. The editor-in-chief and coordinating (lead) editors of Cochrane’s mental health review groups posted a statement in the BMJ’s rapid response section, which was published on 12 May, indicating their areas of agreement and disagreement with his paper and his views on psychiatric medications.

On 6 June, the printed BMJ carried a letter by Gøtzsche in reply to the Cochrane editors. Two days later, the editors issued an erratum notice for Gøtzsche’s letter, indicating it had been edited “for editorial and legal reasons”. His letter was a shortened version of a rapid response (which was also edited). Also in June, Cochrane leadership informed Gøtzsche that if he continued to use Cochrane affiliations in the way he had been, the NCC could be deregistered, and he was asked to apologize for what he wrote about the Cochrane editors. [3]

In a later rapid response, Gøtzsche roughly repeated the allegations he reported others making about the Cochrane editors’ motives as part of apologizing for appearing to impugn their integrity. In August 2018, he put in a slide in a recorded talk with what he says he had to apologize for: “I don’t know whether I should have apologized, but I did”.

>> 

In September, Gøtzsche published a book, Deadly Psychiatry and Organised Denial. As part of the promotion, he wrote an article in the UK tabloid, Daily Mail, claiming that psychiatric drugs are the third leading cause of death in Britain: “it is time for a war on psychiatric drugs,” he wrote. His wording implied the research underpinning this was under the aegis of the CC: “As an investigator for the independent Cochrane Collaboration - an international body that assesses medical research - my role is to look forensically at the evidence for treatments….” CC leadership published a statement that Gøtzsche was entitled to his opinion, but the work was not Cochrane research, and his views did not represent those of the organization or all its members.

>> 

Cochrane infrastructure was centralizing, and this included the decision to move control of the CC-funded information management development team, formerly under NCC leadership, to CC central: although people would remain at the NCC, Gøtzsche was no longer their boss or in control of the budget. The development was opposed by Gøtzsche, and there were, according to Gøtzsche, “protracted negotiations in 2015 involving lawyers on both sides”, including an unsuccessful attempt by him to “seek economic compensation for the Centre” for its past contributions. [1]

 

2016

In May, Gøtzsche wrote to the European Medicines Agency (EMA – the European equivalent of the US FDA) alleging maladministration in relation to evidence on HPV vaccines, on NCC letterhead, signed as Director (with several co-signatories). Journalists contacted the CC asking if this was official, and Gøtzsche was informed this was seen as a breach of the spokesperson policy, with an acknowledgement that the policy needed to be more explicit: it was amended soon after. (You can read the the EMA response here.) There was a high-profile commentary on the episode in a journal that later criticized the spread of “inadvisable anti-vaccination sentiment” about HPV vaccines under the Cochrane banner. (The commentary's authors had also complained to the CC.) The episode was high profile in other areas, too: for example, Irish media later reported on the EU Ombudsman’s conclusion that there had been no maladministration.

>> 

Mark Wilson (CEO) drafted a Memorandum of Understanding (MOU) between CC and Cochrane Centre directors. Some proportion of the directors was up in arms about it. There was a heated dispute with Gøtzsche over the process and the MOU contents, particularly as they related to increased accountability/reduced independence for Cochrane Centres. [2]

>> 

Gøtzsche successfully ran for election to the Cochrane governing board, on a platform of challenging current strategic priorities, directions, and culture, writing in his nomination statement that he was a scientific lobbyist, and including this about the Cochrane Executive Team (CET): “Should the CET decide on what centre directors should be doing when it doesn’t provide their salary and when the centres are on government finances, which come with expectations that might not always coincide with what the CET would want?” He did not disclose that he had very recently had a protracted dispute over CC withdrawing funding from the NCC and rejecting his request for financial compensation.

>> 

An application to trademark the name, The Nordic Cochrane Centre on the NCC’s behalf separate from Cochrane, was lodged for Europe (and later granted).

 

2017

The year began with another dispute about Gøtzsche’s advocacy with the Cochrane mantle, this time, in an interview (done in November 2016) with a broadcaster in Ireland (RTÉ) about the safety of HPV vaccines and his complaint to the EMA: Cochrane again reminded Gøtzsche of his obligations and agreements. [3]

>> 

Gøtzsche said that there were a series of articles in Danish newspapers starting that year that amounted to a concerted campaign “to get me fired and to get my Nordic Cochrane Centre closed down by stripping it from the Government budget”. This included a series of articles from an online health news outlet with allegations that he was not maintaining a boundary between his personal financial interests and the NCC’s public funding, for example, by promoting his books via the NCC website and on publicly funded trips. Gøtzsche lodged complaints with the Press Council that were partially upheld. The hospital that housed the NCC later reported to the outlet that it found no irregularities in the use of public funds: the outlet's writer argued that as the criticism was also a criticism of the adequacy of the hospital’s oversight, an independent evaluation was required.

 

2018

In February, the rumbles in the Danish press became a roar when the broadsheet Weekendavisen published an article that included a variety of medical leaders, including from the National Board of Health, strongly criticizing Gøtzsche’s campaigning and confrontational approach to health issues in recent years, and calling for an independent evaluation of the NCC as his conclusions about evidence and policy were widely disputed. Gøtzsche dismissed the concerns as coming from people with vested interests in the forms of care he was criticizing. Gøtzsche lodged a complaint with the Press Council, which criticized the presentation of one person’s views and the lack of inclusion of Gøtzsche’s response on an issue.

On 8 February, a politician, as leader of a parliamentary committee, lodged a question to the Danish Minister of Health, as to whether the Minister thought she should do something about the concerns raised in Weekendavisen: the Minister indicated she was taking it seriously, saying that the article had made an impression on her, and she would look into the criticisms. The uproar over the Weekendavisen article also revived the online outlet’s allegations about blurring financial boundaries with his books, arousing further political concern.

>> 

In March, 3 separate complaints about Gøtzsche were sent to CC. This time, the dispute erupted across Cochrane’s board as well, with Gøtzsche seeking their support and making allegations about senior staff and one of the CC chairs. Tempers were frayed and the dispute became increasingly bitter. Gøtzsche was again warned that if he continued, the NCC would be deregistered. In June, a majority of the board agreed to commission a lawyer to investigate and advise on 3 specific matters. [3]

>> 

In July, Gøtzsche and 2 colleagues published a critique of the Cochrane review on HPV vaccines to prevent cervical cancer. (The review had been published in May 2018.) In January 2017, Gøtzsche and his co-authors had registered their own systematic review of the vaccines. It was a doctoral project supervised by Gøtzsche. The scope was not just cervical cancer, and it was to be based on “industry clinical study reports, and non-industry published and unpublished reports”. They lodged 2 amendments to that protocol later that same year. In January 2018, they published an index of the studies they found. The Cochrane authors published their own review in May, apparently without having combed through the index.

The July critique of the Cochrane review made a lot of serious criticisms, including that the authors had missed half the trials. It got a lot of publicity. In August, I tried to unpick it all, and wrote a post that was largely critical of the critique, including its accuracy and the validity of some of its claims. (I had a lot of trouble trying to work out their index of studies, too.) I did not know that this was occurring against a backdrop of a major in-house conflict with Gøtzsche. Meanwhile the Cochrane editorial unit put several people onto addressing the critique as a priority, and they asked Gøtzsche & co to provide a list of the studies claimed to be missing. They refused to identify the trials they said were missing. (Source)

Later, Gøtzsche would write in Politiken that the reason for his expulsion was retaliation for his criticism of this review, and that a dispute over scientific censorship was central. (A translation.)

>> 

Around August, the Danish Minister of Health had begun the first formal evaluation ever undertaken of the NCC, later publicly commenting that such long-term allocation of government funding without review was not regular in Denmark. The annual budget allocation from the ministry to the NCC and associated clinical trials unit was US$2.7 million at that point, but it’s not clear how much of that was specifically for the NCC part of Gøtzsche’s work.

>> 

In August, Gøtzsche gave a talk in Berlin at Max Planck titled “Heroes of Science: Survival of a Whistleblower”, in which in which he discussed the history of his grievances with the Cochrane Collaboration.

>>

In September, the CC received an interim report from the lawyer they had commissioned in June, on the 3 specific issues he had been asked to consider. [3] The serious nature of the confidentiality here means I think it’s inappropriate to discuss all the disputed incidents and allegations about what was happening in 2018, or the complex report and its many conclusions. I think the events described demonstrate an irretrievable breakdown in the relationship between Gøtzsche on the one hand, and on the other, senior staff and the various Cochrane chairs in the years leading up to it.

The overall picture is one of the CC leadership continually trying to draw a line, and struggling to find a way to get Gøtzsche to hold it. He sometimes held it, often didn’t, and periodically escalated the behavior several generations of leadership had tried to change, as well as the conflict over that behavior. As Gøtzsche’s non-Cochrane-review campaigning became more inflammatory, the CC’s position was that Gøtzsche should use his University of Copenhagen affiliation or an alternative (or personal) attribution for non-Cochrane-review work, and for promoting or publicly discussing his views based on it, but not the NCC. Despite this having gone on for years, the CC never developed systems or policies adequate enough to deal with a powerful Cochrane Centre director going rogue. The parting of the ways, when it came, went badly.

Gøtzsche was expelled from membership of the Cochrane Collaboration, with a few iterations of explanation as to why. Finally, the CC chairs listed reasons for the expulsion in webinars with membership:

  • “A consistent pattern of disruptive and inappropriate behaviours, over a number of years, which undermined Cochrane’s collaborative culture and were detrimental the charity’s work, reputation and members.
  • A consistent placing of his own interests above those of Cochrane.
  • Behaviours beyond explanation by academic or cultural differences.
  • Multiple warnings were given & conversations took place in concerted attempts to deal constructively with the issues.
  • A repeated representation of personal views as those of Cochrane despite requests and promises not to do so.
  • Multiple complaints to Cochrane over a number of years.
  • Serious, defamatory and outrageous allegations against Cochrane colleagues – and publicly.
  • As a member of the Governing Board, a serious breach of the Trustees’ Code of Conduct.
  • NO allegations of sexual or physical misconduct, or any other criminal activity.”

Key events: the Board decided by a majority to begin the process of expelling Gøtzsche (13 September); all but one had voted that he had breached the Trustees’ Code of Conduct (Board members are Trustees). The day after, 4 board members resigned: 3 of them were from Cochrane Centres, and the fourth was an activist colleague that Gøtzsche had nominated to the Board. (Note: I cannot confirm that last statement. I had noted this in 2018, but when I went to fact check, I could not find documents online for former Board members.) The CC’s annual general meeting (AGM) was on 17 September in Edinburgh (video here). Gøtzsche subsequently reported that a move to unseat the board at the AGM had been organized, but when he signaled for the process to start, his colleagues did not follow through with the plan. As a journalist put it, “No coup materialized”. Gøtzsche was finally officially expelled on 25 September.

>> 

On 26 September, Gøtzsche wrote a response to the Board’s statement, including this response to the statement that he had been warned about his behavior: “This is mendacious. I have never received any warnings about my ‘behaviour’ or any explanation about what is objectionable about my behaviour. Again, the only complaints about me have been in response to my scientific critiques, often by those whose science I have disagreed with. Simply publicly disagreeing with someone’s science is hardly a basis for complaint about my ‘behaviour’.”

>>  

On 28 September, Gøtzsche wrote to the CC withdrawing the NCC from the Collaboration. That reportedly led to the Ministry saying that it would withhold the quarterly payment of funding for the NCC until it could be ascertained that the NCC was part of the Cochrane Collaboration. The Ministry, the hospital, and the CC were all engaged in discussions about the NCC’s status with the CC and whether Gøtzsche could continue to lead it. A representative of the hospital that housed the NCC reportedly said that with a personal conflict of that magnitude, and no longer being a member of the Collaboration, it would not be possible for him to be NCC director, terminating his employment. Gøtszche wrote in Politiken that he considered this “scientific judicial murder”. (According to this translation.)

>>

On 3 September, the Cochrane editor-in-chief published a response to the Gøtzsche & co critique of the Cochrane HPV review from July, which concluded that there was a need to update the Cochrane review, but in their view, it wasn’t urgent as the conclusion would not change. The editors of the journal that published the critique (one of whom is a fairly close colleague of Gøtzsche and one of the other authors) swiftly rebutted the Cochrane editors. So did the Gøtzsche group, adding new criticisms – but they also acknowledged they had made some errors.

On 16 October, the editors of the journal that had published the critique of the Cochrane HPV vaccine review reported that they had investigated the critiques of the critique (including mine), and come to the conclusion that corrections to the paper by Gøtzsche & co were needed. They called for responses to their findings, and said corrections/clarifications would be made within about 6 weeks. I welcomed this, and although their proposed corrections were substantial, I did not think they went far enough, and I wrote a post about it, tweeting the link to them.

Note: Although correction was proposed within six weeks of October 2018, as of 8 February 2020, the critique had no formal correction, and it has no editorial note or link to the editors’ post reporting errors. The Cochrane review has not been updated, and it has no note either of the issues the Cochrane editors identified in their evaluation.

>> 

In October, Gøtzsche complained to the UK Charity Commission, asking them to open a statutory inquiry into the Cochrane Collaboration.

>>

In November, 16 people started “Cochrane Members for Change” based on protesting Gøtzsche’s expulsion and raising a variety of issues, canvassing widely to encourage people to join, including beyond Cochrane’s members (one of those recruitment emails came to me). The group lobbied for a sort of regime change in the elections to fill the places on the Cochrane board vacated in September. Part of the platform for them, and groups in Germany and the Latin American Cochrane Network their website points to, was that there should be a complete review of the decision to expel Gøtzsche from Cochrane.

>> 

Replacement trustees for 4 positions on the Cochrane board were elected in December: no coup had materialized via the electoral process, either. The chairs of the board and Cochrane’s Council (that represents members and staff) published a statement on priorities in response to the Gøtzsche expulsion: an online forum for members, a code of conduct for members, and procedures for dealing with alleged breaches of the code of conduct.

>>

In December, an online petition to the Danish Minister of Health to prevent Gøtzsche’s dismissal from his position in Copenhagen was started, with a goal of 1,000 signatures. (At time of writing, it had over 10,000 signatures.) Gøtzsche also started a GoFundMe campaign to raise around US$1.5 million for “legal costs and to support a new Institute for Scientific Freedom in order to allow Peter to carry on with his work for the benefit of the patients”. (At time of writing, it had raised around US$35,000.)

>>

Also in December, an interview with Gøtzsche aired on German TV, claiming his (as yet unpublished) systematic review had found “serious harms” of HPV vaccines.

 

2019

In February, there was an outbreak of criticism on Twitter about the extremist company that Gøtzsche was keeping, leading him to pull out of a vaccination conference he had planned to speak at.

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Gøtzsche launched an Institute for Scientific Freedom in April. (Videos of the speakers.) The extremist company issue arose again, and plans to publish audience Q&A from the day were abandoned. There’s a lot of reporting on the day by journalist Daniel Kolitz at Undark magazine. Iain Chalmers, who had gotten the whole Cochrane Collaboration ball rolling, was reportedly disturbed by what he saw, from some speakers and the audience: “It had become clear to Chalmers, at least, that in taking on the establishment, Gøtzsche had attracted the wrong crowd”. (Source)

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In April, another Gøtzsche book was published, Survival in an Overmedicated World: Look Up the Evidence Yourself. He has promoted it with this: “Chemotherapy for cancer? Surprisingly, for most cancers it should be avoided”, and making the chapter on cancer treatment free. I haven’t bought the book. However, it was the latest example of his analysis for advocacy while I was preparing this timeline, so I assessed what was presented in the chapter he showcased to gauge the standard of the content. I am not familiar with the overall evidence on chemotherapy for cancers, so I can’t evaluate the claim: only the chapter.

The chapter is under 6 pages long, with 18 references, only 6 of which are about cancer treatment (chemotherapy), and 2 of those are editorials. Only about a page discusses evidence about cancer treatment, mostly about chemotherapy for breast cancer (one of the types of cancer for which he says he probably wouldn’t recommend chemotherapy).

There is only 1 paragraph on his opinion that chemotherapy should be avoided for most cancers. It is based on what he calls a 2004 meta-analysis, but when you go to the reference he cites, it is a 2016 editorial in the BMJ. That editorial cites a 2004 meta-analysis. For one thing, 15 years old is wildly out of date. But when you go to the cited 2004 paper, it’s not a meta-analysis. It’s not a systematic review either. It gives a vague description of a search for studies, and then uses an unspecified selection of literature to estimate how many people’s lives in Australia and the US are extended by chemotherapy alone. When I tried to find a number Gøtzsche discusses as a finding of that study, I couldn’t find it in the paper: it was a number that was in the 2016 editorial, though. Perhaps he didn’t cite the paper directly because he didn’t read it?

There are 3 other paragraphs discussing evidence of the effects of chemotherapy, and they are based on systematic reviews. One reports a 2007 version of a Cochrane review that found a benefit of one type of chemotherapy. A second is a Cochrane review that found only a small benefit of polychemotherapy for women with metastatic breast cancer – but he doesn’t report the evidence was about women with metastatic cancer and doesn’t confine his dismissal of polychemotherapy to women with advanced cancer.

The other paragraph discussing evidence is about a meta-analysis by the Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) that contradicts the conclusion on breast cancer in that 2004 paper Gøtzsche relies on. He writes that you don’t have to spend hours reading and digesting the EBCTCG meta-analysis: “the most important outcome in cancer trials is always total mortality. We do not know whether polychemotherapy reduces total mortality because the 31-page paper does not tell us”. However, the paper does tell us that. Overall mortality is the third outcome the authors list in their methods. Table 2 (nearly half a page) is about all mortality and other breakdowns related to mortality in women having polychemotherapy (and Table 3 is one for women using tamoxifen or not). There is discussion of non-breast cancer mortality at multiple points in the text, and analysis of the potential for death from treatment toxicity.

Although he only spends a paragraph on the evidence in the EBCTCG study, he spends about a page recounting his difficulties finding the study’s appendices. Gøtzsche speaks of his “desperation” trying to find supporting data: “Then began a bizarre type of academic playing hide-and-seek. Nowhere in the paper was even a hint about how to find the appendix”. This is hard to understand: the appendices are very prominent on the website. What’s more, once you get access to the PDF, it also prominently links to the EBCTCG’s own website, which includes a link to a section on the specific meta-analysis, where there is a free version of the article, the press release that went with it, and a link to where the data isn’t behind a paywall as it is at the journal (including an appendix for that Table 2).

The end of this section in Gøtzsche’s chapter suggests this drama about the appendices was included to (a) discredit the paper and its authors, and (b) to further a narrative that he is a dogged sleuth who can find truths despite conspiracies to hide them. Quote:

“Why were there no data on the only unbiased outcome - total mortality - in the 31-page Lancet paper? And why were these data so well-hidden that only people as stubborn as me could find them? This story illustrates what has been documented many times before: academia can be just as biased as the drug industry and just as ‘skilled’ at hiding the most important facts”.

I say “further a narrative”, because it’s a common thread in his writing and advocacy. Here’s an example of the recurring theme, this time from an article in Undark published in December 2019:

‘But when it comes to his books and public persona, he also has a famously take-no-prisoners approach. “I dig so deeply in my research,” Gøtzsche said, “that I find the skeletons people have buried down there. And when I put them up on the ground people yell and scream, and call me all sorts of names, because they didn’t think anybody would ever find the skeletons”.’

>> 

At the end of November, in an interview in Politiken with Gøtzsche on the occasion of turning 70, he reported that his next book would come out in February 2020: the subject is vaccines.

 


 

My conclusions

The conflict that erupted into public in September 2018 fanned the flames of many longstanding arguments about the Cochrane Collaboration. But I don’t think the Cochrane/Gøtzsche blowout happened because of differences over principles, opinions about industry conflicts of interests, or scientific methods. Plenty of people in the Cochrane world hold the same views as Gøtzsche, and just as strongly, yet thrive or at least co-exist within it.

I also don’t think it was because of his criticism of the Cochrane HPV vaccine review. I think the conflict that became public in September was already at the irreconcilable differences stage in June when a lawyer was commissioned. That was before Gøtzsche’s criticism of that review was published. The way he went about that critique, including refusing to provide a list of the trials claimed to be missing from the review, doubled down on conflict with the CC and suggests he had no interest in de-escalation. It certainly inflamed the situation, but it wasn’t the cause.

I don’t think it was because of a dispute over Cochrane’s move to being very commerce-oriented either. That wasn’t new by a long way. The NCC had been a long-term major beneficiary of its proceeds: his campaign protesting Cochrane’s strategic direction began just months after Cochrane stopped providing a significant portion of its commerce-derived funds to the NCC annually, not when the direction was set and its negative consequences became obvious many years earlier.

I think it was because since 2014, two developments were propelling the parties to a high-speed collision. One was Cochrane’s organizational development eroding both Gøtzsche’s autonomy as a Cochrane Centre director and the Centre’s finances, and that was his power base. The other was Gøtzsche ramping up the extremism, scope, and volume of public campaigning that could harm people’s health, often explicitly in Cochrane’s name, always with his mantle of Cochrane credibility, and entwined with selling books for personal profit. That not only resulted in further erosion of his autonomy specifically as a prominent Cochrane leader: it increased scrutiny in Denmark of his local public funding and raised demands for accountability there for the funding and for his actions, thus jeopardizing the rest of his NCC financial and power base. Gøtzsche was, I think, vigorously painting himself into a corner that he wouldn’t be able to fight his way out of.

Gøtzsche has written: “The [2014] letter from Cochrane’s leadership”, that disowned his views about psychiatry and psychiatric drugs, “was a threat to what I had built up over 30 years, including my centre, which is on government funding”. Apparently, even public concern expressed by the Minister of Health a couple of months before that was not enough for Gøtzsche to consider that it was his rhetoric in the media that posed the threat.

In my opinion, he badly over-estimated the cards he held, and failed to read the room. In December 2018, in his Politiken op-ed, he wrote that he had argued the Ministry should change the NCC’s name and dump Cochrane, in favor of funding him to continue on the path he had been on – when it was precisely that path that appears to me to have become politically radioactive in Denmark.

The Cochrane name enabled Gøtzsche to rise to prominence. Withdrawing the Cochrane mantle from his battles has damaged the Collaboration’s credibility with some people, but it will preserve (or restore) Cochrane’s credibility for others in the medical and public health communities he has targeted. Far more importantly, stopping Gøtzsche using Cochrane’s credibility was critical to limiting how many people could be harmed after acting on his claims when they were dangerous ones not based on Cochrane reviews.

It was common, when the part of this that occurred in the English-speaking world became very public, for people to argue Cochrane should have done more to resolve the conflict with Gøtzsche. That would certainly have affected how some people reacted to the split. However, I don’t believe anything could have resolved the conflict. Cochrane’s basic request was, I believe, reasonable. I was very publicly outspoken under that same kind of expectation in the years I worked for the NIH, for example: it’s common outside universities. I could find nothing to indicate that Gøtzsche would consider changing course under any circumstances. Indeed, that refusal to ever budge is one of the reasons many admire and applaud him.

The barrage of controversy and conflict Gøtzsche generates impresses and excites some people, too, or it's considered just a nuisance, worth putting up with. But for others, it’s at best an exhausting drain of energy away from more constructive effort, and at worst personally traumatizing. The more targets Gøtzsche picked, the more he was criticized or attacked – and the more he attacked back and attacked others. Gøtzsche has been the subject of major attacks, for sure, including ones that were unfair or included misinformation. I don’t believe, though, that this justifies his own behavior. Most people would find it difficult to be at the receiving end of the kind of rhetoric and accusations that Gøtzsche uses about colleagues, other individuals, or whole clinician communities – especially in the cases where he is more powerful than the people he is attacking, and/or they cannot avoid or ignore him because of their job or Cochrane position.

Warrior culture is inimical to collaboration, I wrote in 2002 in response to the mammography battle. But warriors are praised for bravery, and the term iconoclasts ­– who historically were destructive and at times violent – is used admiringly. I think warrior behavior is inimical to properly debating scientific findings, too. Yet people cheer warriors on, and they can accrue vocal adherents and powerful enablers, thanks to common interests/ideologies, and camaraderie from shared past battles. It’s a common problem in activist communities.

Neither an affinity for conflict nor wanting to be at the cutting edge of challenging the establishment are inherently in the public interest or the interests of science. They can be twin drivers, though, to extremism. As I’ve said before: “I think the main thing I learned – very painfully – in 20 years as a health consumer advocate, is that zealots always, always end up hurting patients. Because whatever it is that they are against, is not the same as being for patients, and it will, inevitably, betray us”.

Rigorous science was key to whether the positions Gøtzsche advocated so fiercely were beneficial or harmful to the public. The rigor he has been applying, though, varies greatly to say the least, especially in the books that underpin his campaigning, and his rhetoric is often not calibrated to the strength of evidence for the causes he champions. So the circle of support and tolerance for what he was doing started to waver and reduce in his academic and mainstream media worlds. His self-belief and resolve appeared, though, to be strengthened, if anything, by widening circles of opposition.

It seems to me from reading what he has written, that he would never see a boundary between his non-Cochrane and his Cochrane work, or between himself and “his” Centre. It’s no wonder, then, if he feels betrayed by the Cochrane Collaboration not stepping up to defend his activism. If it wasn’t about Cochrane reviews, though, there was no reason the Collaboration should have defended it, and several reasons why it shouldn’t. Even had the CC backed him to the hilt, I doubt that that would have protected him in the long term in his battle with the medical community locally: it seems to me more likely that the Danish government would have stepped away from Cochrane, with the Copenhagen ship going down with its captain.

In 2018, Gøtzsche increasingly turned the force of his social power explicitly against the Cochrane Collaboration, urging others to take up the battle, too. He gives the impression he wants to ensure its downfall. But the organization can thrive without Gøtzsche. And it has been weathering his public attacks for years. However, had the Cochrane Collaboration continued to provide a high-profile platform for campaigning on an expanding raft of controversial health positions not based on its reviews, then it ran the risk of being an organization doing more harm than good to public health (and deservedly losing credibility, too). The Collaboration isn't a university, and it isn't a broad health lobby: it's an organization with a specific remit about its own systematic reviews, and has been from the start. I haven't detected an appetite for changing that fundamental purpose, even amongst people who have argued for other change in response to this episode.

To me, this sad story is a signal lesson in the importance of accountability, especially for those funded with the public’s money. Gøtzsche worked hard to create a comfortable cocoon of grant-application-free long-term public funding of a team to be able to study what he wanted, how he wanted to, and to communicate it in the mass media. It was possible in that constellation because of trust for the Cochrane name. Walking away from co-authors and medical journal peer review for analyses for his advocacy freed him from even more constraints. Gøtzsche seems keen to replicate the model in his Institute for Scientific Freedom. He said this at the symposium launching it:

“I would suggest we have a very small advisory board, because the idea is just that we have some people we can ask for advice when we need advice. It’s not about having meetings, and –– I hate bureaucracy. I want to get things done! So the less bureaucracy we can have in this Institute the better. And I can tell you, then you have the right Head, because I hate bureaucracy. So there will be very little bureaucracy. Now, the overall purpose is very simple: to preserve honesty and integrity in science….”

Too much bureaucracy is bad, for sure. But for a research institute, so is too little. Transparency and accountability, even when you don’t think you need advice, safeguard honesty and integrity in public life. Skirting around anyone who could slow you down and make you consider and justify things more carefully, and demonizing people who criticize your ideas or your tactics, is not a path to integrity, good science, or policy in the public interest.

Gøtzsche has said: “My view is that a hero is someone who has other genes than non-heroes…There are a few odd people like me who have something different in our genes….” It’s a biological trait that constitutes him for leadership, and communities turn to people like him with these “special genes” in a crisis, he said. I think that belief and self-image explains a lot. I am glad the Cochrane Collaboration is no longer tethered to every issue he might take up.

Hilda Bastian

8 February 2020

Note: I continue to call the organization the Cochrane Collaboration, even though it now brands itself as “Cochrane” instead. I do so, not just because I feel strongly about the “collaboration” part of the name, but because the name of the charity has not actually been changed.

 


 

The Cochrane Collaboration

(Organizational website)

Peter Gøtzsche

(Personal website; Institute for Scientific Freedom website)

  • At BMJ Blogs: “Cochrane – no longer a collaboration”
  • In Politiken, “My dismissal is scientific judicial murder” (translation)
  • A talk at CrossFit, Santa Cruz in June 2019 on YouTube
  • In the Indian Journal of Medical Ethics: “What is the moral collapse in the Cochrane Collaboration about?” (Note: that includes some claims about me, to which I respond * below.)
  • His book: “Death of a whistleblower and Cochrane’s moral collapse”

 * The section entitled “Hilda Bastian, a non-leading scholar”, includes the following about my blog post I wrote on the original critique of the Cochrane HPV vaccine:

  • This quote: “Given the personal history you have with Dr Gøtzsche … particularly over mammography, I think you could have disclosed that to readers … Hate distorts the personality of the hater ...” That post originally referred people to my disclosure statement at the foot of the post, which included the statement: “I have butted heads on the subject of bias with authors of the Copenhagen critique”, which was my declaration that I had prior conflicts with authors (one of whom was Gøtzsche). When I shortly after specifically wrote about CC’s conflict with Gøtzsche, I prominently included my disagreement with him around 2002. To the best of my memory, the critique of the critique of the HPV vaccine was the first time I had published a critique of his work other than the mammography review.
  • This statement about: “She calls our group ‘anti-vaxxers’…” This is what I actually wrote in that post: “These arguments about safety are the focus of Skeptical Raptor’s post describing the Copenhagen group as Cochrane’s ‘anti-vaxxers’, which is a good lead-in to their next critique.” I don’t think Gøtzsche and his co-authors of that critique are opposed to all vaccines in principle, and I am sure I have never said so. However, I have written elsewhere that I believe his advocacy and approach to issues are hampered by anti-industry bias.

 


 

Contrary viewpoints

 


 

My posts

List of things I’ve published about, or related to, the conflict between Gøtzsche and the rest of the Cochrane Collaboration (* means it's also about HPV vaccines):

List of things I’ve written about the HPV vaccine debate, in addition to those marked * above:

 

[References]

Please see note on sources in the introduction.

[1] Peter Gøtzsche’s 66-page response to a confidential report by a lawyer commissioned by the Cochrane Collaboration dated 30 August 2018. Via Gøtzsche’s personal website.

[2] Appendix 12 of the above [1].

[3] The confidential report by the lawyer, mentioned above.

 

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