Intended for healthcare professionals

Analysis And Comment Controversy

Parachute approach to evidence based medicine

BMJ 2006; 333 doi: (Published 28 September 2006) Cite this as: BMJ 2006;333:701
  1. Malcolm Potts, Bixby professor, population and family planning1,
  2. Ndola Prata (, lecturer1,
  3. Julia Walsh, adjunct professor1,
  4. Amy Grossman, research assistant1
  1. 1 School of Public Health, University of California, 314 Warren Hall, Berkeley, CA 94720, USA
  1. Correspondence to: N Prata
  • Accepted 19 June 2006

Waiting for the results of randomised trials of public health interventions can cost hundreds of lives, especially in poor countries with great need and potential to benefit. If the science is good, we should act before the trials are done

In 2003 Smith and Pell published an entertaining but profound article titled: “Parachute use to prevent death and major trauma due to gravitational challenge.”1 They used the lack of randomised controlled trials in testing parachutes to show that situations still exist where such trials are unnecessary. We argue that the parachute approach, where policies are set based on good science but without randomised trials, is often more suitable in resource poor settings. We use the examples of oral rehydration therapy, male circumcision to prevent HIV infection, and misoprostol for postpartum haemorrhage to show how an overemphasis on randomised controlled trials in poor settings poses important ethical and logistic problems and may incur avoidable deaths.

Childhood diarrhoea and oral rehydration therapy

In 1980 childhood diarrhoea was killing an estimated 4.6 million children annually.2 Treatment with an intravenous drip is life saving but requires health facilities. Studies from 1977 onwards showed that infant diarrhoea could be treated with oral rehydration.3 The World Health Organization initiated a highly successful programme of oral replacement therapy in 1981 after it became obvious that the treatment saved lives and no alternative home based treatment was possible.4 Randomised controlled trials were later conducted in health facilities, confirming that oral replacement therapy was as effective as intravenous therapy.56 The initiation of large scale programmes for oral replacement therapy before the randomised trials meant that by 2000 there were three million …

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