In the early 1980s, there was growing concern about the quality of peer review at scientific journals. So two researchers at Cornell and the University of North Dakota decided to run a little experiment to test the process.

The idea behind peer review is simple: It’s supposed to weed out bad science. Peer reviewers read over promising studies that have been submitted to a journal to help gauge whether they should be published or need changes. Ideally, reviewers are experts in fields related to the studies in question. They add helpful comments, point out problems and holes, or simply reject flawed papers that shouldn’t see the light of day.

The two researchers, Douglas Peters and Stephen Ceci, wanted to test how reliable and unbiased this process actually is. To do this, they selected 12 papers that had been published about two to three years earlier in extremely selective American psychology journals.

The researchers then altered the names and university affiliations on the journal manuscripts and resubmitted the papers to the same journal. In theory, these papers should have been high quality — they’d already made it into these prestigious publications. If the process worked well, the studies that were published the first time would be approved for publication again the second time around.
What Peters and Ceci found was surprising. Nearly 90 percent of the peer reviewers who looked at the resubmitted articles recommended against publication this time. In many cases, they said the articles had “serious methodological flaws.”
This raised a number of disquieting possibilities. Were these, in fact, seriously flawed papers that got accepted and published? Can bad papers squeak through depending on who reviews them? Did some papers get in because of the prestige of their authors or affiliations? At the very least, the experiment suggested the peer review process was unnervingly inconsistent.
The finding, though published more than 30 years ago, is still relevant. Since then, other researchers have been uncovering more and more problems with the peer review process, raising the question of why scientists bother with it in the first place.

All too often, peer review misses big problems with studies

Researchers who have examined peer review often find evidence that it works barely better than chance at keeping poor-quality studies out of journals or that it doesn’t work at all. That conclusion has been arrived at in experiments like this one or this one and systematic reviews that bring together all the relevant studies, like this one and this one.
The reasons it fails are similar to the reasons any human process falls down. Usually, it’s only a few reviewers who look at an article. Those reviewers aren’t paid for their time, but they participate out of a belief in the scientific process and to contribute to their respective fields. Maybe they’re rushed when reading a manuscript. Maybe they’re poorly matched to the study and unqualified to pick it apart. Maybe they have a bias against the writer or institution behind the paper.
Since the process is usually blinded — at least on the side of the reviewer (with the aim of eliciting frank feedback) — this can also up the snark factor or encourage rushed and unhelpful comments, as the popular #sixwordpeerreview hashtag shows.

The Lancet editor Richard Horton has called the process “unjust, unaccountable … often insulting, usually ignorant, occasionally foolish, and frequently wrong.” Not to mention that identifying peer reviewers and getting their comments slows down the progress of science — papers can be held up for months or years — and costs society a lot of money. Scientists and professors, after all, need to take time away from their research to edit, unpaid, the work of others.

Richard Smith, the former editor of the BMJ, summed up: “We have little or no evidence that peer review ‘works,’ but we have lots of evidence of its downside.” Another former editor of the Lancet, Robbie Fox, used to joke that his journal “had a system of throwing a pile of papers down the stairs and publishing those that reached the bottom.” Not exactly reassuring comments from the editors of the world’s leading medical journals.

Should we abolish peer review?

So should we just abolish peer review? We put the question to Jeff Drazen, the current editor of the top-ranked medical publication the New England Journal of Medicine. He said he knows the process is imperfect — and that’s why he doesn’t rely on it all that much.
At his journal, peer review is only a first step to vetting papers that may be interesting and relevant for readers. After a paper passes peer review, it is then given to a team of staff editors who each have a lot of time and space to go through the submission with a fine-toothed comb. So highly qualified editors, not necessarily peer review, act as the journal’s gatekeepers.

“[Peer review] is like everything else,” Drazen said. “There are lots of things out there — some are high quality, some aren’t.”

Drazen is probably onto something real in that journal editors, with enough resources, can add real value to scientific publications and give them their “golden glow.” But how many journals actually provide that value add? We’re probably talking about 10 in the world out of the tens of thousands that exist. The New England Journal of Medicine is much more an outlier than the rule in that regard.

Even at the best journals, ridiculously flawed and silly articles get through. A few readers can’t possibly catch all the potential problems with a study, or sometimes they don’t have access to all the data that they need to make informed edits.
It can take years, multiple sets of fresh eyes, and people with adversarial views for the truth to come to light. Look no further than the study that linked autism to the measles-mumps-rubella vaccine, published in the Lancet. That paper was retracted after it was found to be not only fraudulent but also deeply flawed.

For some, that’s a reason to get rid of peer review. Brandon Stell, the president of the PubPeer Foundation, favors “post-publication” peer review on websites like his own (Pubpeer.com). There, users from around the world can critique and comment on articles that have already been published. These crowdsourced comments have led to corrections or even retractions of studies.

“There’s no reason why we couldn’t publish everything immediately on the internet and have it peer-reviewed after it’s been published,” Stell said arguing for abolishing pre-publication peer review. There are already journals that do just this, he added, such as the Winnower.

But replacing one flawed system (traditional pre-publication peer review) with what may be another (post-publication peer review) doesn’t fully solve the problem. Places like PubPeer are a fantastic development, but it’s not yet clear that they’re significantly better at catching errors and bad science consistently compared with traditional pre-publication peer review.
Even with its flaws, at the very least peer review seems to work at least a little better than chance. That’s not great, but that may be better than nothing. In a world without the peer review culture, it’s possible even more bad science would sneak through.

A complex solution for a complex problem

Stell pointed to another great innovation: sites like Biorxiv, which allow researchers to “pre-print” their manuscripts online as soon as they’re ready and get open comment before they’re ever peer-reviewed and published in academic journals. This adds another step in the process to publication, another chance to filter problems before they make it to peer review and onto the scientific record.
Ivan Oransky, a medical journalist who tracks retractions in journals at his site Retraction Watch, had a more holistic view. He didn’t think post-publication review should supplant the traditional process, but that it should be an add-on. “Post-publication peer review is nothing new, but in the past it’s happened in private, with no feedback for the authors or larger scientific community,” Oransky said. Sites like PubPeer open up the process and make it more transparent, and should therefore be strengthened.
“Let’s stop pretending that once a paper is published, it’s scientific gospel,” he added.

We think that’s closer to the solution. Science would probably be better off if researchers checked the quality and accuracy of their work in a multi-step process with redundancies built in to weed out errors and bad science. The internet makes that much easier. Traditional peer review would be just one check; pre-print commenting, post-publication peer review, and, wherever possible, highly skilled journal editors would be others.

Before this ideal system is put in place, there’s one thing we can do immediately to make peer review better. We need to adjust our expectations about what peer review does. Right now, many people think peer review means, “This paper is great and trustworthy!” In reality, it should mean something like, “A few scientists have looked at this paper and didn’t find anything wrong with it, but that doesn’t mean you should take it as gospel. Only time will tell.”
Insiders like journal editors have long known that the system is flawed. It’s time the public embraced that, too, and supported ways to make it better.

Last week Vox correspondent Dylan Matthews chastised hedge fund manager John Paulson for donating $400 million to Harvard University, and asked people to stop giving Harvard money because they’d largely be serving rich kids. “Literally any other charity is a better choice,” he argued.
Now, admittedly, I’m biased. In addition to being a Vox contributor, I’m also an adjunct associate professor at Harvard. But Matthews is mistaken for one simple reason: he assumes universities only exist to educate students. That’s absolutely wrong.

Universities are more than just training centers

Today, education is only one increasingly small part of a university’s mission. Just look at Harvard’s spending:

How Harvard spends its money. (Harvard.edu)

Only a tiny portion of Harvard’s $4.4 billion annual budget goes to supporting its 6,700 college students. Instead, 49 percent goes to supporting its 2,400 faculty members, 10,400 academic appointments in affiliated hospitals, and thousands more research associates, lab managers, librarians, and administrators.

This means it is the other parts of a university’s mission — producing knowledge through systematic inquiry (i.e., research) and promoting the use of this knowledge for public good (i.e., dissemination) — that get prioritized. Gifts to research-intensive universities should therefore be evaluated according to how much knowledge and public good they are likely to yield, in addition to how many and what kinds of students they train.

To be clear, I’m not saying that handing Harvard a fortune is the best use of Paulson’s money. It’s probably not. Like all places where cash is plentiful, money is wasted and fat could be trimmed. (I heard from friends that the catered food at Paulson’s Harvard announcement was “epic.”) I am just saying that gifts to rich research-intensive universities are still probably a relatively good use of that money. At the very least it’s not a bad use of it.

A ranking system like GiveWell wouldn't have helped Paulson

John Paulson gave Harvard $400 million. (Pat Greenhouse/the Boston Globe via Getty Images)

Is there a better way for rich people like John Paulson to give away their money? Matthews’s idea is to donate according to GiveWell’s rankings. This works well for small-time donors — probably you and definitely me — but it’s not feasible when we’re talking about $400 million. There is just no way that GiveWell’s top-ranked charity, Against Malaria Foundation, for example, could absorb that kind of cash when its annual operating budget hovers around $3.5 million.

The other problem with GiveWell is that it focuses on scaling up existing interventions rather than discovering new ones. Research charities are consequently excluded. The reality is that we won’t save our world during any of our lifetimes without more research.

Even the most optimistic models for achieving a “grand convergence” in under-5 mortality rates between rich and poor countries, for example, depend on doubling annual research funding for neglected diseases from today’s $3 billion to $6 billion. Relying on what already exists just won’t get us there.

Impact of enhanced health investments on under-5 mortality rate in low- and lower-middle-income countries. (Global Health 2035)

A better strategy for donating to science: "insider giving"

If I had $400 million to give to science, I would channel the money to rising research stars who are 1) younger, 2) underfunded, 3) interdisciplinary, and 4) defying tradition. My strategy would work because I have some insider knowledge on which researchers are doing new, groundbreaking work and which are unlikely to produce transformative results.
It’s a strategy that is analogous to “insider trading” on the stock market, except this strategy — let’s call it “insider giving” — is legal and should be encouraged. Through it we get the benefits of insider knowledge without the accompanying jail time.

But how do rich, non-expert, busy billionaires participate in insider giving? The answer is that they can’t — at least not directly. Instead, they need to give their money to people who do have this insider knowledge.

Universities, as institutions, have it in abundance. Their leaders probably know which of their top-notch scholars could make greatest use of any donation.
Harvard is also a university with a demonstrated track record of using this insider knowledge to achieve great social impact. There is no denying the many remarkable contributions Harvard researchers have made to society through their production and dissemination of knowledge. In the medical field, Harvard researchers discovered nuclear magnetic resonance (used for medical imaging), invented the pacemaker (which treats arrhythmias), and developed the first transgenic mouse (helpful for cancer research).

Misunderstanding universities makes us all poorer

So mega-donations to research-intensive universities like Harvard are certainly not “a gigantic, immoral waste of money,” as Matthews argued. Such donations are nearly assured to achieve social impact. At the very least it’s better than buying another yacht or making a donation to the National Rifle Association (which would also get Paulson a massive tax write-off).

Most critiques of Paulson’s $400 million gift to Harvard stem from a fundamental misunderstanding of the role that today’s universities play in our society. Such narrow and misinformed views threaten to undermine the transformative role that universities can play in producing and disseminating knowledge to address our most difficult and pressing challenges. Failing to understand that makes all of us poorer.

In the wake of the police-involved deaths of black men including Michael Brown and Eric Garner last year, thousands have protested across America to turn our collective attention to the different treatment of black and white people at the hands of America’s criminal justice system.
The focus, of course, is much needed. But there’s discrimination in many other places, too. Every single day, there are many more race-related deaths that result from a quieter problem: systemic discrimination in the US health system.
The truth is this: even today, in America, white privilege works better than most medicine when it comes to staying healthy. Racial health disparities may be a more subtle killer than gun violence or murder, but they’re arguably a more violent one. They infect every part of the body, and they strike at literally every stage of life, from cradle to grave.
Baltimore or Ferguson — the site of recent riots — have life expectancies and infectious diseases rates that hover near those of the developing world. These cities can be seen as microcosms of a much larger problem. “If the statistics that are present in these communities were present in any white community in Baltimore,” Douglas Miles, a Baltimore pastor, told the New York Times, “it would be declared a state of emergency.”

The gap starts with birth

Simply put, black babies don’t have a fair start. Pre-term delivery — coming into the world at less than 37 weeks — is one of the key causes of infant death in the US. These early births lead to a host of health complications, both short and long term, from vision and hearing impairment to cerebral palsy. Black women have a 43 percent higher risk than white women for delivering their babies prematurely. They are also between two and three times as likely to have babies dangerously early, in less than 32 weeks.
When it comes to nursing, black mothers are consistently less likely to breastfeed than white mothers, despite the guidelines suggesting all mothers do so because of well-documented health benefits. This gap has been explained by everything from preference to a lack of access and education about health benefits to a dearth of support for new moms. The latest data from the Centers for Disease Control and Prevention showed that hospitals in predominantly black neighborhoods also do less to promote breastfeeding than mostly white hospitals.

The black-white health divide continues throughout life
In childhood, black kids are more likely to suffer asthma and obesity. They have poorer oral health than white people. The health problems trickle into adulthood, when diabetes strikes black people much more often than it does white people: in 2010, the prevalence of obesity in black people was nearly twice that of white people.

Of all racial groups, African Americans suffer the most from HIV. Of all racial groups, black women have the highest breast cancer death rates; they’re 40 percent more likely to die of the disease than white women.

The number of new HIV infections in the US by demographic group. Note, MSM means “men who have sex with men” and IDUs means “injection drug users.” (Chart courtesy of the CDC.)

This disparity isn’t only explained by differences in access to care. Even when black and white people have the same cancer screening, black people are more likely to die from the disease. The latest study on this issue examined the differences in cervical cancer treatment of black and white women in Maryland. Maryland was a good place to test that hypothesis, since there is a state-sponsored screening program to support women and black and white women are being screened at the same rate.
After accounting for stage of cancer at diagnosis, the treatments received were still different. White women got surgery more, while black women were more likely to get radiation or chemotherapy combined with radiation. Such a treatment disparity may be what’s driving the fact that in the US, black women are more likely to have cervical cancer (see chart below) and twice as likely to die from it as white women.

(Courtesy of PLOS One)

Near the end of life, the disparities persist. Black people have the highest death rates from stroke and hypertension, and the largest incidence and highest death rates from colorectal cancer. Compared with white patients, black patients are much less likely to get the life-saving organ transplants they need.

One study looked at people with end-stage kidney disease in six states, examining their likelihood of being placed on a waiting list for a donor organ and whether they wanted a referral in the first place. The results are deeply disturbing. “In contrast to the relatively small differences in preferences and expectations about transplantation,” the study authors wrote, “black patients were much less likely than white patients to have been referred to a transplantation center for evaluation; they were also much less likely to have been placed on a waiting list or to have received a transplant within 18 months after the initiation of dialysis.”

Black women are treated the worst

One theme in this damning body of evidence is that black women are affected most by this disparity: they’re the population that suffers from both a racial and gender effect. Take this classic study published 15 years ago in the New England Journal of Medicine. Researchers presented 720 physicians from across America with one of eight random videos of an actor conveying symptoms and asked them to make health-care recommendations. The eight videos were exactly the same — identical script, identical emotions — except that the actors differed in age, sex, and race.

(Courtesy of the New England Journal of Medicine)

Unfortunately, the physicians did not do so well. When the actors were women or black, the doctors were less likely to refer them for cardiac catheterization. Black women fared worst of all as the least likely group to benefit from doctors’ recommendations to seek follow-up care. The study demonstrated that doctors sometimes carry deeply ingrained racial biases into the clinic, which can have a harmful effect on patients.

Black people have fewer years on Earth than white people

All these health disadvantages add up to a lifespan that’s cut short: black men can still expect to live five years less than white men, and black women can expect to live four years less than white women. There are no biological or genetic explanations for this difference. Four and five years is a lot of life: it’s the length of time it takes to complete college or to see your child through to kindergarten.

(Courtesy of the CDC)

Why the persistent gap?

Thomas LaVeist, director of the Hopkins Center for Health Disparities Solutions at the Johns Hopkins Bloomberg School of Public Health, has been studying racial disparities for decades. When he did his PhD dissertation in the 1990s, he calculated how many infant deaths were associated with being black, and the stunningly high numbers drained him. Since then, he says, not much has changed.
Even when you control for education and income, black people still fare worse than white people, and he thinks one key cause is everyday racism.
“These little microaggressions include things like going to a reception and sipping a glass of wine, and no one talks to you; trying to go into an elevator and someone doesn’t hold the door for you; or walking into the elevator and someone moves further away as if they’re concerned about you snatching their purse,” he said. “These things are happening at a subconscious level, and they have a physiological and psychological response. That degrades your health, and it has been shown to degrade the strength of the immune system.”
For years now, researchers like LaVeist have been meticulously documenting the ways black patients get inferior care and have worse health outcomes than other racial groups. Over a decade ago, the Institute of Medicine even published a definitive report on the subject, concluding that many of the differences in health care received between white and black Americans was the result of unacceptable discrimination.

The evidence is clear
We don’t need more evidence about the existence of these unacceptable racial disparities and discrimination. When you look at the fullness of a life, and all the points at which that life intersects with the health system, and then at how much worse off black people fare every time, you can see there is a violence and injustice here.
That’s something we should all fight against. LaVeist says some are already taking the first steps to address the problem. He’s putting together a documentary about the black-white health gap, which highlights solutions. On the community level, he found educators in Los Angeles who are trying to teach people how to grow their own healthy food. In Mississippi, he found a pastor who banned soul food in his church. One woman in Nashville goes door to door teaching people how to do CPR, because so many studies have shown that African Americans are less likely to know CPR.
On the policy level, the Affordable Care Act has expanded access to more than 30 million people. “It’s not sufficient to address the health disparities problem,” says LaVeist, “but it’s an important and necessary condition.”
Still, evidence suggests that the ACA isn’t working as well for black Americans as it is for other racial groups: their uninsured rates have only dropped from 21 percent to 20 percent since the legislation was introduced. So the ACA is a start — it’s foundational — but it’s still failing African Americans.

Right now, in 2015, despite all the advances of medicine in the past 100 years, despite this groundbreaking health-care legislation, despite having a black president in the White House, the black-white health gap isn’t going away.
We often focus on medicine and the latest technology in health. Yet what dictates how healthy you’ll be throughout life — and all the promise and opportunity that cascades from that — is something a lot more basic. In America, it’s still the color of your skin.

Welcome to Burden of Proof, a regular column in which Julia Belluz (a journalist) and Steven Hoffman (an academic) join forces to tackle the most pressing health issues of our time — especially bugs, drugs, and pseudoscience thugs — and uncover the best science behind them. Have suggestions or comments? Email Belluz and Hoffman or Tweet us @juliaoftoronto and @shoffmania. You can see previous columns here.

Welcome to Burden of Proof, a regular column in which Julia Belluz (a journalist) and Steven Hoffman (an academic) join forces to tackle the most pressing health issues of our time — especially bugs, drugs, and pseudoscience thugs — and uncover the best science behind them. Have suggestions or comments? Email Belluz and Hoffman or Tweet us @juliaoftoronto and @shoffmania. You can see previous columns here.

Another day, another diet study. In one week, it’s not unusual to find two studies on the same topic with contradictory conclusions — in this case, about what kind of eating would help people lose the most weight.

Those studies are not exceptional. There are at least 75 randomized controlled trials published every day — and that number continually increases. According to Google CEO Eric Schmidt, every couple of days we now create the same amount of information that we did from the dawn of civilization all the way up until 2003.

Part of this new knowledge includes an overwhelming quantity of health information. It’s constantly produced, reproduced and transmitted to public audiences. Not only are we confused; even the best scientists can’t stay on top of it all. Much of it is wrong.

This has led us to a frustratingly paradoxical place: we have more science than we’ve ever had to make the best possible decisions about our health. Yet in reality, this knowledge usually hits us like a tsunami. We’re drowning in bytes of data we don’t know how to make sense of. Despite all the advances in science, it can even seem as though we’re moving away from evidence-based thinking and toward magical beliefs in miracle cures and fast-fixes.

A lot of the information out there is simply wrong. Consider this recent study of Wikipedia entries about medical conditions: not only did they contain many errors, but nine out of ten of the articles examined significantly deviated from the best-available evidence.

The challenge before us is this: how can we find and capitalize on all good information — and avoid wrong information — to have healthier lives and societies?

Julia Belluz on Dr. Oz’s big weight-loss lies (and one truth).

How doctors beat the deluge of medical evidence
Like their patients, doctors used to scramble in the information deluge. They’d often end up using outdated information from medical school or authority figures — and not the best-available evidence — to guide their practices.

Then, in the early 1990s, came “evidence-based medicine.” It sounds redundant, almost silly, but it was a revolution in medical practice. Essentially, the movement called on doctors to apply the scientific method to the clinics through “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”

One of the key insights of evidence-based medicine was that doctors needed accessible and trustworthy research to inform their decisions. They, too, needed help wading through all the research out there.

Statisticians paved the way by coming up with particular methods for making sense of science. One of the earliest examples was published by the British Medical Journal in 1904. Back then, a statistician named Karl Pearson was asked by the government to look at whether a vaccine against typhoid fever had reduced infection and death among soldiers who had used it in various parts of the British Empire. In his review, he looked at data from places like South Africa and India, and pointed out all their flaws and weaknesses, suggesting that an experiment — calling for volunteers to take the vaccine, and giving every other one a dose — would be needed to find out whether it actually worked.

A nerdish revolution
Pearson laid the groundwork for this idea that researchers needed to look critically at medical evidence and combine the results of many studies to find out where bias or holes in the science might lurk.

The group that’s done more to further that cause than perhaps any other is the Cochrane Collaboration, an international not-for-profit established in the early 1990s. You’ve probably never heard of it (incidentally, like the evidence-based medicine movement, it was also co-founded by prudent Canadians) but they’re one of the best sources for unbiased medical information in existence and they should be your first stop before you hit Google or WebMD.

Their mandate is to create syntheses of science — known as “systematic reviews” — on important clinical questions. The idea is simple and should sound familiar by now: many studies, involving thousands of patients can get us closer to the truth than any single study or anecdote ever could.

Combining the results of a bunch of studies also reduces bias and the play of chance that can color individual studies. So the folks at Cochrane designed a process for their systematic reviews. Basically, independent reviewers use well-established and transparent protocols to search the literature about health questions and then apply statistical methods to combine them so that they can see where the preponderance of evidence lies. The process is called “meta-analysis” and it’s repeated at least twice and then published so that others can verify or repeat their steps. After all, not all systematic reviews are created equally.*

We can do better than Dr. Google

Today at Cochrane, you’ll find reviews on everything from the effects of acupuncture for preventing migraines (maybe works) and premenstrual syndrome (may not work), to the usefulness of cranberry juice to treat bladder infections (probably doesn’t work). The hard-working people behind Cochrane even translate their conclusions into “plain language summaries” and podcasts.

These summaries are considered the gold standard of medical evidence because they allow doctors to make decisions not just on the basis of whatever random research they come across, but on the totality of science about whatever medical question they have.

Now, there are a number of other databases that bring together high-quality reviews on health issues and the Cochrane methodology has been applied to other areas of science — from education and crime to health systems questions. (See chart below.) These summaries are more accessible than ever before, not just for doctors, but also for the rest of us.

Databases of Systematic Reviews

Cochrane Database of Systematic Reviews

Systematic reviews on health issues.

Database of Abstracts of Reviews of Effects

Systematic reviews on health issues.

Evidence Updates

Systematic reviews on clinical issues.

Health Evidence

Systematic reviews on public health issues.

Health Systems Evidence

Systematic reviews on health systems issues.

Campbell Collaboration Library of Systematic Reviews

Systematic reviews on education, crime and justice, and social welfare.

PubMed Health

Systematic reviews on health issues.

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If you don’t find information about the health question you’re researching in one of these databases, there are other good, evidence-based sources. Try MedlinePlus, Mayo Clinic, and NHS Choices. For more reliable health information, bookmark this page on the top 100 health websites you can trust. And if you want to nerd out about medical evidence check out the book Testing Treatments, which is free to download.

Evidence-based medicine is not perfect, of course, and doctors still sometimes make decisions that aren’t rooted in science.

But the idea behind it is one that should guide our health choices: not all evidence is created equally, and it shouldn’t be acted upon as such. What’s more, the sheer quantity of new health science — and the huge opportunity it represents — means that we have to change the way we make decisions. To do that, there are better places to start than Dr. Google.

*Footnote: Check out the Cochrane Collaboration logo. It has a cool story behind it.

The horizontal lines on the logo represent seven experiments looking at whether a course of corticosteroids for women who were expected to give birth prematurely reduced the risk of death in their babies. The left-hand side of the circle means the results of the studies were positive and the drug was proven to be useful; the right-hand side means the opposite was shown to be true. The middle, vertical line means there was ‘no difference,’ or that the drug may or may not work. And the diamond represents the combined results of all the studies.

As you can see, most of the studies showed the drug worked and the combined results came out in support of using corticosteroids in mothers to save their babies’ lives. But until the first systematic review was published almost 20 years after the drug hit the market, doctors were left to wade though contradictory studies on the question and basically guess about what to do with their patients. Thousands of babies suffered and died needlessly.