Alessandro Liberati

BMJ 2012; 344 doi: (Published 16 February 2012) Cite this as: BMJ 2012;344:e1101
  1. Nicola Magrini,
  2. Richard Smith
  1. Correspondence to: R Smith richardswsmith{at}

Campaigned for high quality evidence relevant to patients

With his splendid name, fiery red hair, utter disdain for Silvio Berlusconi, and passion for Internazionale (the left wing team for those who don’t know soccer), Alessandro Liberati had the look and feel of an Italian revolutionary. But he was a gentle and convivial revolutionary, regularly hosting the “libertrophy,” a weekend party of fun and games at his family home in Tuscany. At his funeral in the packed Romanesque Basilica of Santo Stefano in Bologna, his daughter Valeria read his last letter, in which he hoped that there would be a special libertrophy “characterised by high spirits and by the desire to be together.”

Butterfly behaviour

Alessandro’s revolutionary fervour had clear aims: improving the quality of evidence available to patients and their clinicians; ensuring, as he wrote in the BMJ in 2004, that “research results should be easily accessible to people who need to make decisions about their own health” (BMJ 2004;328:531, doi:10.1136/bmj.328.7438.531); and trying to encourage researchers to concentrate on research that mattered to patients not to their careers or to drug companies. “How far can we tolerate,” he wrote, “the butterfly behaviour of researchers, moving onto the next flower well before the previous one has been fully exploited.”

These were concerns of Alessandro’s early in his career after graduating in medicine from the University of Milan in 1978, but they were given a poignant intensity when in 1997 he was diagnosed as having “monoclonal gammopathy of uncertain significance (MGUS).” Modern medicine, he wrote, seems to be “good at creating ‘new diseases’ without necessarily knowing how to cure them.”

After working for four years as a clinician and at the Instituto Mario Negri he won a scholarship to the Harvard School of Public Health and worked with Tom Chalmers, one of the first to promote systematic reviews of medical evidence. Alessandro learnt his trade working on important systematic reviews of treatment of early breast cancer and the effectiveness of antibiotic prophylaxis in patients in intensive care.

When the call came from Iain Chalmers, and others at the BMJ, in 1992 to start the Cochrane Collaboration, the international effort to synthesise medical evidence, he was one of the first to respond, and he contributed to the initial meeting of the collaboration in Oxford in 1993. Some have observed that the highly rational processes of evidence based medicine have been embraced more enthusiastically in northern, protestant countries than in southern, catholic ones, but Alessandro ensured that the Italian Cochrane Centre, which he led, was one of the first to be active. When he organised one of the early Cochrane Colloquium in 1999 in the beautiful building in Rome “where the pope went to school,” the Italian minister of health emphasised the importance of evidence based medicine. Alessandro had influence: “He was a precursor of social networks in public health,” says Maurizio Bonati, head of the department of public health at the Istituto Mario Negri, Milan, “making researchers work and stay together.”

The most relevant evidence

But he was not a fanatic for evidence based medicine, says his colleague Marina Davoli. He rejected “the simplistic dichotomy . . . between experimental and observational studies . . . and the concept of the ‘evidence hierarchy’ [which puts systematic reviews at the top and case studies at the bottom].” Instead of asking “What is the best type of evidence?” she continues, he suggested asking, “What is the most relevant evidence [for this decision to be taken], and what is its quality?”

Alessandro was also in recent years concerned about fraud in medical research and the malignant influence of conflicts of interest. He feared that the well of research might be poisoned and worried that newspapers like the New York Times might be better than medical journals at exposing and exploring conflicts of interest.

When he developed MGUS, he looked for the best evidence available and found that published reports didn’t help much. Small studies suggested that the risk of malignant transformation was between 7% and 19%. Should he be monitored? Should he be treated? There was little evidence, but he had fought the “excesses of medicalisation in oncology” and so opted for no treatment. In 2002 his condition progressed to myeloma, and he was treated with a bone marrow transplant in May 2003. Should he have a second transplant? There had been four trials, but much to his irritation they weren’t yet published. He went on to a second one in September 2003, moving into territory where evidence had little to say, but early trials may have overstated the benefits of a double transplant.

Just a few weeks before he died Alessandro published a letter in the Lancet in which he looked at the 1384 studies of multiple myeloma available in July 2011 and discovered that only 10 had overall survival as a primary endpoint and that there were no head to head trials of different treatments (Lancet 2011;378:1777-8, doi:10.1016/S0140-6736(11)61772-8). In other words, few of the studies were answering the questions that matter most to patients. He concluded, “If we want more relevant information to become available, a new research governance strategy is needed.”

In his final years he had the chance to put his philosophy of improving clinical research governance into practice as the manager of research in the Regional Agency for Health and Social Care in Emilia-Romagna. Roberto Grilli, head of the agency, describes how he developed a process for selecting research studies to be funded, “focused on assessing not only their methodological robustness but also their potential relevance to patients and health care delivery.” Grilli observes that what made Alessandro a “special person” was that his considerable scientific skills were “always backed by good beliefs and values mixed up with civil passion.”

Alessandro leaves a wife, Mariangela, and two daughters.


Cite this as: BMJ 2012;344:e1101


  • Alessandro Liberati, health services researcher and founder of the Italian Cochrane Centre (b 1954; q 1978, University of Milan) died on 1 January 2012 from multiple myeloma.