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Highlights from Nirmala Sitharaman’s maiden Budget Speech

News Intervention Bureau
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Highlights from Nirmala Sitharaman’s maiden Budget Speech

Indian Finance Minister Nirmala Sitharaman presented the country’s General Budget for financial year 2019-20. Excerpts from her speech.

“Our economy was at approximately US$ 1.85 trillion when we formed the Government in 2014. Within 5 years it has reached US$ 2.7 trillion. Hence, it is well within our capacity to reach the US$ 5 trillion in the next few years. In the interim Budget of 2019-20 presented in February 2019, we gave ourselves a Vision for the Decade. I flag here the ten points of our Vision laid before us:

  1. Building physical and social infrastructure;
  2. Digital India reaching every sector of the economy;
  3. Pollution free India with green Mother Earth and Blue Skies;
  4. Make in India with particular emphasis on MSMEs, Start-ups, defence manufacturing, automobiles, electronics, fabs and batteries, and medical devices;
  5. Water, water management, clean Rivers;
  6. Blue Economy;
  7. Space programmes, Gaganyan, Chandrayan and Satellite programmes;
  8. Self-sufficiency and export of food-grains, pulses, oilseeds, fruits and vegetables;
  9. Healthy society – Ayushman Bharat, well-nourished women & children. Safety of citizens;
  10. Team India with Jan Bhagidari. Minimum Government Maximum Governance.”  

“The Indian economy will grow to become a $3 trillion economy in the current year. It is now the sixth largest in the world. Five years ago, it was at the 11th position. In Purchasing Power Parity terms, we are in fact, the 3rd largest economy already, only next to China and the USA.”

“Connectivity is the lifeblood of an economy. The Government has given a massive push to all forms of physical connectivity through Pradhan Mantri Gram Sadak Yojana, industrial corridors, dedicated freight corridors, Bhartamala and Sagarmala projects, Jal Marg Vikas and UDAN Schemes. While the industrial corridors would improve infrastructure availability for greater industrial investment in the catchment regions, the dedicated freight corridors would mitigate the congestion of our railway network benefitting the common man. The ambitious programme of Bharatmala would help develop national road corridors and highways, while Sagarmala would enhance port connectivity, modernization and port-linked industrialization. If Sagarmala is aimed at improving the infrastructure for external trade, equally it is the poor man’s transport too. Waterways are proven as a cheap mode of transport. The Jal Marg Vikas project for capacity augmentation of navigation on National Waterways is aimed at smoothening internal trade carried through inland water transport. These initiatives will improve logistics tremendously, reducing the cost of transportation and increasing the competitiveness of domestically produced goods.”

Finance Minister Nirmala Sitharaman presenting the General Budget 2019-20 in the Lok Sabha at Indian Parliament in New Delhi on Friday, July 05, 2019.

“India’s first indigenously developed payment ecosystem for transport, based on National Common Mobility Card (NCMC) standards, was launched by Hon’ble Prime Minister in March, 2019. This will enable people to pay multiple kinds of transport charges, including metro services and toll tax, across the country. This inter-operable transport card runs on RuPay card and would allow the holders to pay for their bus travel, toll taxes, parking charges, retail shopping and even withdraw money.”

“Phase-II of FAME Scheme, following approval of the Cabinet with an outlay of Rs 10,000 crore for a period of 3 years, has commenced from 1st April, 2019. The main objective of the Scheme is to encourage faster adoption of Electric vehicles by way of offering upfront incentive on purchase of Electric vehicles and also by establishing the necessary charging infrastructure for electric vehicles. Only advanced battery and registered e-vehicles will be incentivized under the Scheme with greater emphasis on providing affordable & environment friendly public transportation options for the common man.”

“We need to develop our inland waterways to shift a significant portion of inland cargo movement from road and rail. This Government envisions using the rivers for cargo transportation, which will also help to decongest roads and railways. As part of the Jal Marg Vikas Project for enhancing the navigational capacity of Ganga, a multi modal terminal at Varanasi has become functional in November 2018 and two more such terminals at Sahibganj and Haldia and a navigational lock at Farakka would be completed in 2019-20. The movement of cargo volume on Ganga is estimated to increase by nearly four times in the next four years. This will make movement of freight, passenger cheaper and reduce our import bill.”

“It is estimated that Railway Infrastructure would need an investment of Rs 50 lakh crores between 2018-2030.  Given that the capital expenditure outlays of Railways are around Rs 1.5 to 1.6 lakh crores per annum, completing even all sanctioned projects would take decades. It is therefore proposed to use Public-Private Partnership to unleash faster development and completion of tracks, rolling stock manufacturing and delivery of passenger freight services.”

“For ease of access to credit for MSMEs, Government has introduced providing of loans upto Rs 1 crore for MSMEs within 59 minutes through a dedicated online portal. Under the Interest Subvention Scheme for MSMEs, Rs 350 crore has been allocated for FY 2019-20 for 2% interest subvention for all GST registered MSMEs, on fresh or incremental loans.

“It is right time to consider increasing minimum public shareholding in the listed companies. I have asked SEBI to consider raising the current threshold of 25% to 35%.”

“FDI inflows into India have remained robust despite global headwinds. Global Foreign Direct Investment (FDI) flows slid by 13% in 2018, to US$ 1.3 trillion from US$ 1.5 trillion the previous year – the third consecutive annual decline, according to UNCTAD’s World Investment Report 2019. India’s FDI inflows in 2018-19 remained strong at US$ 64.375 billion marking a 6% growth over the previous year. I propose to further consolidate the gains in order to make India a more attractive FDI destination:

  • The Government will examine suggestions of further opening up of FDI in aviation, media (animation, AVGC) and insurance sectors in consultation with all stakeholders.
  • 100% Foreign Direct Investment (FDI) will be permitted for insurance intermediaries.
  •  Local sourcing norms will be eased for FDI in Single Brand Retail sector.” 

“India has emerged as a major space power with the technology and ability to launch satellites and other space products at globally low cost. Time has come to harness this ability commercially. A Public Sector Enterprise viz. New Space India Limited (NSIL) has been incorporated as a new commercial arm of Department of Space to tap the benefits of the Research & Development carried out by ISRO. The Company will spearhead commercialization of various space products including production of launch vehicles, transfer to technologies and marketing of space products.”

“Pradhan Mantri Awas Yojana – Gramin (PMAY-G) aims to achieve the objective of “Housing for All” by 2022. A total of 1.54 crore rural homes have been completed in the last five years. In the second phase of PMAY-G, during 2019-20 to 2021-22, 1.95 crore houses are proposed to be provided to the eligible beneficiaries. These houses are also being provided with amenities like toilets, electricity and LPG connections. With the use of technology, the DBT platform and technology inputs, average number of days for completion of houses has reduced from 314 days in 2015-16 to 114 days in 2017-18.”

“Ensuring India’s water security and providing access to safe and adequate drinking water to all Indians is a priority of the Government. A major step in this direction has been the constitution of the Jal Shakti Mantralaya, integrating the Ministry of Water Resources, River Development and Ganga Rejuvenation and Ministry of Drinking Water and Sanitation. This new Mantralaya will look at the management of our water resources and water supply in an integrated and holistic manner, and will work with States to ensure Har Ghar Jal (piped water supply) to all rural households by 2024 under the Jal Jeevan Mission. This Mission, under the Department of Drinking Water and Sanitation, will focus on integrated demand and supply side management of water at the local level, including creation of local infrastructure for source sustainability like rainwater harvesting, groundwater recharge and management of household wastewater for reuse in agriculture. The Jal Jeevan Mission will converge with other Central and State Government Schemes to achieve its objectives of sustainable water supply management across the country.”

“Swachh Bharat Abhiyan has touched the very conscience of the nation besides bringing enormous health and environmental benefits. This noble Scheme, initiated in 2014, has achieved a resounding success. 9.6 crore toilets have been constructed since Oct 2, 2014. More than 5.6 lakh villages have become Open Defecation Free (ODF). We have to build on this success. We must not only sustain the behavioural change seen in people but also harness the latest technologies available to transform waste into energy. I now propose to expand the Swachh Bharat Mission to undertake sustainable solid waste management in every village.”

“We propose to establish a National Research Foundation (NRF) to fund, coordinate and promote research in the country. NRF will assimilate the research grants being given by various Ministries independent of each other. NRF will ensure that the overall research eco-system in the country is strengthened with focus on identified thrust areas relevant to our national priorities and towards basic science without duplication of effort and expenditure. We would work out a very progressive and research oriented structure for NRF. The funds available with all Ministries will be integrated in NRF. This would be adequately supplemented with additional funds.”

“The Government is proposing to streamline multiple labour laws into a set of four labour codes. This will ensure that process of registration and filing of returns will get standardized and streamlined. With various labour related definitions getting standardized, it is expected that there shall be less disputes.”

“I propose to consider issuing Aadhaar Card for Non-Resident Indians with Indian Passports after their arrival in India without waiting for 180 days.”

“Financial gains from cleaning of the banking system are now amply visible. NPAs of commercial banks have reduced by over Rs 1 lakh crore over the last year, record recovery of over Rs 4 lakh crore due to IBC and other measures has been effected over the last four years, provision coverage ratio is now at its highest in seven years, and domestic credit growth has risen to 13.8%. Government has smoothly carried out consolidation, reducing the number of Public Sector Banks by eight.  At the same time, as many as six Public Sector Banks have been enabled to come out of Prompt Corrective Action framework.”

“Government has announced its intention to invest Rs 100 lakh crore in infrastructure over the next five years. To this end, it is proposed to set up an expert committee to study the current situation relating to long-term finance and our past experience with development finance institutions, and recommend the structure and required flow of funds through development finance institutions.”

“Government is setting an enhanced target of Rs 1,05,000 crore of disinvestment receipts for the financial year 2019-20. The Government will undertake strategic sale of PSUs. The Government will also continue to do consolidation of PSUs in the non-financial space as well.”

“Let me recall and reiterate this Government’s effort over the past five years to alleviate the tax burden on small and medium income-earners. This includes self-employed as well as small traders, salary earners, and senior citizens. Only when their annual taxable income exceeds Rs 5 lakh, they are required to pay any income tax.”

“So far as corporate tax is concerned, we continue with phased reduction in rates. Currently, the lower rate of 25 % is only applicable to companies having annual turnover up to Rs 250 Crore. I propose to widen this to include all companies having annual turnover up to Rs 400 crore.  This will cover 99.3% of the companies. Now only 0.7% of companies will remain outside this rate.”

“Considering our large consumer base, we aim to leapfrog and envision India as a global hub of manufacturing of Electric Vehicles. Inclusion of Solar storage batteries and charging infrastructure in the above scheme will boost our efforts. Government has already moved GST council to lower the GST rate on electric vehicles from 12% to 5%. Also to make electric vehicle affordable to consumers, our government will provide additional income tax deduction of Rs 1.5 lakh on the interest paid on loans taken to purchase electric vehicles. This amounts to a benefit of around Rs 2.5 lakh over the loan period to the taxpayers who take loans to purchase electric vehicle.”  

“Start-ups in India are taking firm roots and their continued growth needs to be encouraged.  To resolve the so-called ‘angel tax’ issue, the start-ups and their investors who file requisite declarations and provide information in their returns will not be subjected to any kind of scrutiny in respect of   valuations of share premiums. The issue of establishing identity of the investor and source of his funds will be resolved by putting in place a mechanism of e-verification.  With this, funds raised by start-ups will not require any kind of scrutiny from the Income Tax Department.”

Interchangeability of PAN and Aadhaar

“Mr Speaker, Sir, more than 120 Crore Indians now have Aadhaar. Therefore, for ease and convenience of tax payers, I propose to make PAN and Aadhaar interchangeable and allow those who do not have PAN to file Income Tax returns by simply quoting their Aadhaar number and also use it wherever they are required to quote PAN.”

“Mr Speaker Sir, as I have stated earlier, we have taken several measures in the past to alleviate the tax burden on small and medium income-earners as those having annual income up to Rs 5 lakh are not required to pay any income-tax. We are thankful to the taxpayers who play a major role in nation building by paying their taxes. However, in view of rising income levels, those in the highest income brackets, need to contribute more to the Nation’s development. I, therefore, propose to enhance surcharge on individuals having taxable income from Rs 2 crore to Rs 5 crore and  Rs 5 crore and above so that effective tax rates for these two categories will increase by around 3 % and 7 % respectively.”

“We are further simplifying the GST processes. A simplified single monthly return is being rolled out. Taxpayer having annual turnover of less than Rs 5 crore shall file quarterly return. Free accounting software for return preparation has been made available to small businesses. A fully automated GST refund module shall be implemented.  Multiple tax ledgers for a taxpayer shall be replaced by one.”

“Make in India is a cherished goal.  In order to provide  domestic industry a level playing field, basic customs duty is being increased on items such as cashew kernels, PVC, Vinyl flooring, tiles, metal fittings, mountings for furniture, auto parts, certain kinds of synthetic rubbers, marble slabs, optical fibre cable, CCTV camera, IP camera, digital and network video recorders etc. Also, exemptions from custom duty on certain electronic items which are now being manufactured in India are being withdrawn. Further, end use based exemptions on palm stearin, fatty oils, and exemptions to various kinds of papers are also being withdrawn. To encourage domestic publishing and printing industry, 5 % custom duty is being imposed on imported books.”

“To further promote domestic manufacturing, customs duty reductions are being proposed on certain raw materials and capital goods. These include certain inputs of CRGO sheets, amorphous alloy ribbon, ethylene di-chloride, propylene oxide, cobalt matte, naphtha, wool fibres, inputs for manufacture of artificial kidney and disposable sterilised dialyser, and fuels for nuclear power plants. To further incentivise e-mobility, customs duty is being exempted on certain parts of electric vehicles. Customs duty is also being exempted on capital goods required for manufacture of specified electronic goods.”

“Export duty is being rationalised on raw and semi-finished leather to provide relief to this sector.”

“Crude prices have softened from their highs. This gives me a room to review excise duty and cess on petrol and diesel. I propose to increase Special Additional Excise duty and Road and Infrastructure Cess each by one rupee a litre on petrol and diesel. It is also proposed to increase custom duty on gold and other precious metals from 10% to 12.5%.”

Powerful performances by children enthrall audience at Bal Utsav 2019

Shivangini Gupta
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Powerful performances by children enthrall audience at Bal Utsav 2019

When children are given a stage, they make sure to put their best foot forward. This was recently seen at the Bal Utsav organized by the Hindi Academy, when hundreds of students, in the age group of 8-16 years, from various government schools presented plays on hard-hitting social issues and enthralled the audience with their acting and performance skills. The festival was a welcome attempt to enrich the young minds, and make them understand various contemporary social problems.

Inaugurated by Manish Sisodia, Deputy Chief Minister, Delhi government the six-day event was hosted at Pyarelal Bhawan Sabhagar. The students were trained in theater performance free of cost by Hindi Academy. It turned out to be a great opportunity for many underprivileged children, who can’t manage to pay the fees to participate in theatre workshops to explore their hidden talent.

The stories portrayed by children on stage were handpicked by the Academy and allotted to the directors to train and prepare students to perform them. It was a challenge for many directors and their team as they had to creatively push children to come out of their comfort zone and work together as a team to bring a story to the audience in a sensitive way, justifying the sentiments of the author related to the story. Dr. Jitram Bhatt, Secretary of the Hindi Academy, who also moderated the six-day event, said, “Through these plays, the versatility of children develops. Simultaneously, cultural consciousness ignites and it expands positivity in students. We are trying to promote our culture and literature. The literature can only be promoted if the young mind is nurtured and made aware of our culture from the beginning itself.”

The six-day festival showcased plays like “Panch Biradri” written by Lakhan Lal Pal, a story on a battle, directed by Ashish Sharma ‘Ladai’ written by Sarveshwar Dayal Saxena and directed by Javed Abraham. ‘Ladai’ portrays the grave situation of corruption in India. Sharing his experience of working with children Javed says, “Adults are easy to direct as compared to children, but I will prefer working with children any day, as they are so enthusiastic and open to new ideas.” “These workshops help children to polish and hone their inner talent, as they can’t afford to visit expensive acting classes,” Jawed added.

Other plays that were performed included “Mithaiwala” written by Bhagwati Prasad Vajpayee, “Sapno Ki Unchai” written by Ramakant and directed by Arvind Singh, “Raja Ke Kapde Desh Badal-Badal Kar Vikas Kia” written by Manoj Kumar Pandey and directed by Priyanka Sharma, “Rang-Abir” written by Bhagwan Das and directed by Nilesh Deepak. “Faisla” performed on the last day was written by Maitri Pushpa and directed by Sandeep Rawat. On the reason behind the story, Pushpa Maitri shares, “I’ve grown up seeing women being suppressed in my village. When one lady from my village was elected as chief of the village, but her decisions were made by her husband, I was astounded to see the ground reality of women empowerment.” Sandeep Rawat, director of ‘Faisla’ asked the children in his team to collect data and statistics on how many women have been elected as MLA in recent elections. The children were surprised to find out that only 70 members were female out of 400 elected MLA. “Collecting the data helped them understand the situation faced by women,” Sandeep added. Talking about the experience of training children Sandeep said, “It’s always a pleasure to work with young minds, they are very versatile and perform by putting their heart out for their performance.”

One of the plays also touched upon the issue of domestic violence. The play depicted how one vote can make a huge difference and how Basumati was pushed to reach her freedom from an abusive relationship. Two lead actors of the play, Ishan and Sneha, shared, “We thought that domestic violence is history now. But when Sandeep sir gave us assignments to research about the condition of women at the grass-root level in the country, we realized what it is like to live in rural areas as a woman in our country.”

While the performers were ecstatic, the audience was equally enthralled. Rahul, a 22-year-old boy was overwhelmed by watching the children perform. “I have been coming here from the first day, but I did not anticipate that the children will be so perfect at portraying the emotions and the sensitivity of the story,” he shared. Asha, a 43-year-old lady, whose child was also performing in the play was overwhelmed by her child’s performance. “I did not know that my boy could understand topics like this and then perform it in such away. I am grateful to the organizers for giving him this chance and training him,” she shared. The six-day festival concluded with an award ceremony followed by melodious Rajasthani Lok sangeet.

(All photographs clicked by Shrikant Kukreti)

“Defence Expert” doles out bundle of lies on politicization of Indian armed forces

Nilesh Kunwar
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“Defence Expert” doles out bundle of lies on politicization of Indian armed forces

Lately, politicization of the Indian Army has become the pet subject of discussion and debate amongst those who specialize in matters military and their overall prognosis of the situation presents a rather grim picture. In one such piece titled ‘At the doorstep of Indian military politicization’ (Kashmir Times, June 26, 2019), Ali Ahmed has discussed this issue and concluded that the apolitical character of the Indian armed forces is under serious threat. Whereas the author must surely be having good reasons for his convictions, but the credibility factor of any argument nose-dives the moment one allows unfettered speculation to overwhelm logical assessment.

This is exactly what has happened in this case.

According to the author, the Indian Air Chief “rewrote history” when he spoke about Pakistan Air Force (PAF) fighter jets not having crossed the Line of Control (LoC) after the Balakot strike. He goes on to mention how “The air force has gone out of its way to bolster the ruling party head’s questionable claim that some 300 terrorists perished in its aerial surgical strike.” What the author doesn’t realise is that since this attack failed to cause any damage, whether the PAF did or didn’t intrude into Indian airspace has become a non-issue and being irrelevant, even political parties have lost interest in the same.

As far as mentioning terrorist casualty figures are concerned, it needs to be remembered that while the Indian Air Force (IAF) has the ability to carry out post-strike damage assessment of the target by examining the visible impairment, it doesn’t have the electronic and human intelligence capability to conduct internal damage evaluation of its targets. So, since the IAF is merely repeating the casualty figures put out in public domain by the centre, it would be unfair to term this as a motivated act of appeasing the government. Lastly, if the author considers the claim of some 300 terrorists being killed in Balakot airstrike “questionable” and believes that nothing of this sort happened, then he may like to ponder over why did the Pakistan Army delay visit of journalists to the target area by nearly one-and-a-half-month?  

The author goes on to note that “the army chief has endeared himself to the government in his leading the army,” and what exactly he’s hinting at initially escapes interpretation. But things become clear when he states that the army chief’s “personal interest is in his justifying to himself – as much as to others – his controversial elevation to the job based on his counter insurgency expertise, and also the government’s line through its first term resulting in over 600 youth dead.” This complex elucidation raises concerns on whether the army chief has in any way violated the constitutional charter of the army by its mis-employment merely to appease the government, and if so, why hasn’t the author quoted specific instances of the same?

The next issue concerns the author’s view that the army chief’s bid to prove his credentials as a counter insurgency expert and toe the government line left “over 600 youth dead.” This is certainly a very serious allegation and that’s why it’s unfathomable why the author has failed to corroborate the same by revealing who these 600 deceased youth were; under what circumstances were they killed and why? Could this be an inadvertent oversight or an intentional omission just to avoid disclosing the fact that most of these were armed terrorists killed in gunfights with security forces?

 Passing off the Pulwama car bomb suicide attack on a CRPF bus that claimed 40 lives as a “false flag operation” without even providing an iota of evidence to support this bizarre claim is a highly irresponsible act since it could further traumatize the already grieving kith and kin of those who lost their lives in this attack. If this was indeed a false flag operation (as the author is suggesting), then why hasn’t he explained what made Jaish-e-Mohammad (JeM) take responsibility for the same and end up landing in trouble with its chief Masood Azhar being designated a global terrorist by the UNSC (United Nations Security Council)? By making his outlandish false-flag allegation, isn’t the author overstepping established norms of civility and showing scant regards for human sensitivities in his bid to sensationalize this humongous human tragedy?

The way things are going, it seems that the day isn’t far when someone will come out with the claim that JeM chief Masood Azhar is actually an Indian ‘mole’ who had been ‘cultivated’ by Indian spy agency R&AW during his long imprisonment in Indian jails. Then, in order to facilitate his ‘seamless insertion’ into Pakistan and avoid suspicion, R&AW setup the entire IC 814 hijack drama that originated in Nepal and ended in Kandahar. The creator of this ‘Kandahar conspiracy theory’ would then claim that Masood Azhar was ‘activated’ by his masters in New Delhi to organize the Pulwama suicide attack with the help of Indian intelligence agencies so that the BJP could extract electoral advantage from this tragedy !!

Giving wings to one’s imagination is fine, but, even the wildest flights of fantasy must have some limits!

The author has come up with specific predictions but the chances of him eating his own words are rather dim because he has balanced the odds very well. Mentioning that the present air chief “is likely lining up for a kick upstairs, as no less than India’s first Chief of Defence Staff equivalent,” he has simultaneously also hinted that the present army chief could also get this job as “the army latest play of music for the ears of its political master has been the rejection of any notion that surgical strikes were also carried out by the opposition when in government.” Similarly, while he uses this surgical strike issue to suggest that the northern army commander is playing hard ball to become army chief, he counter-balances this by talking of “a current frontrunner for next army chief (who) has links with the new ruling party working head, dating to their juvenile friendship.”

So, no matter who becomes what in the days to come, the author’s prognosis will in one way or the other prove to be correct- and that’s exactly what writing on military related issues and being a ‘defence expert’ is all about!

Fractures of Bones and the Costs of Competent Research

Scott Douglas Jacobsen
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Fractures of Bones and the Costs of Competent Research

Professor Gordon Guyatt, MD, MSc, FRCP, OC is a Distinguished University Professor in the Department of Health Research Methods, Evidence and Impact and Medicine at McMaster University. He is a Fellow of the Canadian Academy of Health Sciences.

The British Medical Journal or BMJ had a list of 117 nominees in 2010 for the Lifetime Achievement Award. Guyatt was short-listed and came in second-place in the end. He earned the title of an Officer of the Order of Canada based on contributions from evidence-based medicine and its teaching.

He was elected a Fellow of the Royal Society of Canada in 2012 and a Member of the Canadian Medical Hall of Fame in 2015. He lectured on public vs. private healthcare funding in March of 2017, which seemed a valuable conversation to publish in order to have this in the internet’s digital repository with one of Canada’s foremost academics.

For those with an interest in standardized metrics or academic rankings, he is the 14th most cited academic in the world in terms of H-Index at 240 and has a total citation count of more than 247,000. That is, he probably has among the highest H-Indexes, of any Canadian academic living or dead.

Scott Douglas Jacobsen: So, you’ve also done some work with regards to fractures of bones. Now, it is not necessarily your main stream of research. We were talking off tape about two particular narratives.

One with regards to the pluses and minuses of a big nail and a small nail with the regards to the tibia. Another with regards to an ultrasound device. You noted the devices have a less strict qualification system to get them certified than do pharmaceuticals or drugs.

Distinguished Professor Gordon Guyatt: Yes! It is dramatic. The standards to get a drug on the market are moderately high. They are not as tough as they used to be, and that is an area of controversy, but they are still substantially more stringent than devices.

Devices can get out there much easier than you can drugs. The review process and the barriers you have to jump over are much less with devices than drugs.

Jacobsen: That also leads to of question that is a preface to all of this. Why did the strictures for pharmaceuticals go down? Why are devices less strict than pharmaceuticals in general?

Guyatt: In terms of the first question, there is a controversy, so there is a trade-off. So, some people would say, “Let’s get new drugs out to people, where previously it took too long.” We had these drugs that are beneficial.

There are all these obstructions and the poor patients are suffering because the drugs are not coming out soon enough. On the other hand, there is another argument that it is not infrequent that drugs come out. We find out bad things about them later; that even apparent benefits do not benefit people. So, on the one hand, good drugs get out, and do not make people wait.

On the other hand, be appropriately cautious, make sure that people are benefiting, and make sure and be more careful about the potential adverse effects, that is the argument back and forth. I am not sure that there is any definitive right or wrong.

But there are many of us who have concerns about the pharmaceutical industry and the way the pharmaceutical industry operates. We are on the side of, “Come on. Wait. Do not do it too soon. Make sure it is right, and better too. There are lots of good drugs on the market now.”

“Unless, something is a real breakthrough. Wait to make sure that it is a breakthrough,” it is more of an small incremental game. Let’s test it before it gets out. So, that is the tension as far as that is concerned.

Jacobsen: To the second question, it had to do with devices having much lower standards.

Guyatt: It is a historical accident. So, way back in the early 60s, what changed the landscape with respect to drugs was thalidomide, it was given to women to prevent the nausea of pregnancy. It ameliorated the problem.

However, it caused these horrible limb abnormalities in the kids. People said, “Oh! You’ve got to do things differently here. This is bad news.” So, it changed the environment as far as drugs. Where I suppose, there haven’t been any particular catastrophes in terms of devices.

They are seen as potentially less dangerous and the culture of tough regulation has never grown up.

Jacobsen: Now with regards to fractures of bones, what is the background with regards to doing some side research with Jason W. Busse regarding?

Guyatt: First, there is Mohit Bhandari. So, Mohit Bhandari is an orthopaedic surgeon who came to me when he was still in his training as an ambitious young guy. He came to me wanting to train in research methods, which is what I train people in. He said, “I’d like to do a big orthopaedic trial.”

So, I said, “I tell you what. Here is the trial you want to do,” and it was this trial of when people fractured their tibia. You need to put a nail in to hold the pieces of the tibia together again properly.

There are two ways of putting the nail in. You put in a little nail that maintains the blood supply in the bone marrow. Or you put in a big nail that requires reaming out the bone marrow and the little nail has the advantage of maintaining the blood supply, which is promoting healing.

The big nail has the advantage of the structural bed being a better structure. So, Mohit said, “It is a real controversy whether we should be using these big nails or small nails. We should sort that out.”

So, I said, “Okay, tell you what, tell me who the leading guy in North America is in this field. Let’s see if he would be interested in heading up a trial where we do this.”

So, we got in touch with him. He is in the States. Let’s talk to him. So, we talked to him. We said, “We are want to do clinical trials. Would you be interested in leading the trial because we need some established authority to lead to trial?” So, he said, “Sure.”

So, he helped us gain access to leading orthopaedic colleagues.” Eventually, we got the trial funded in part in Canada and in the States. Mohit led the trial. By the time the trial was finished, he was on faculty as an investigator and ended up leading the trial to completion and getting the appropriate credit as the leader of the trial.

So, we enrolled over twelve hundred patients, which was a big trial at the time. It was one of the biggest in orthopaedic trauma that had previously been done. It found out that, overall, it did not make much difference whether you used a big nail or the small nail, but possibly a small nail was better in the more severe fractures.

The big nail was better in the less severe fractures and ended up as one of the first big major orthopaedic trauma trials.

Jacobsen: Why the small nail for big fractures and the big nail for the small fractures?

Guyatt: The theory: surgeons before they started had this suspicion. They said, “In the cases of the more serious fractures, the maintaining of the blood supply may be more important. In the less serious fractures, the maintaining of the blood supply is not as important.”

That was the rationale beforehand. They had the idea. So, it became more credible because they had the idea in advance when we found that the small nail seemed to be better in the more serious fractures. The big nail in the less serious.

It made us more inclined to believe that because that was the hypothesis that the surgeons stated and they had some biology for it before the trial started.

Jacobsen: with regards to the last part of the research which regards to fracture bones at least that we have talked about on tape one of them has to do with an ultrasound device.

Guyatt: Okay! So, story, there is so a guy named Jason W. Busse. Another guy who did a Ph.D. with me. By training, he is a chiropractor, but he got interested in research. He came to work with us. He was also working closely with Mohit.

So, the opportunity came along; I am sure through Mohit. I do not remember the details. It was with a company that makes an ultrasound device, which was reportedly enhancing the healing of fractures and in keeping with the lower standards of evidence for our devices.

This device has been licensed for use on the basis of some evidence – not convincing, not strong. These are not high quality studies. It is based on the enhanced radial x-ray healing of fractures and the company then said, “We think our device is great. Let’s get some randomized trials strong and randomised trial evidence about the effect of the device.”

So, we arranged. We made a deal with the company. Jason W. Busse was leading the trial. He set up a randomized trial of this ultrasound device. We got some funding from the industry. We got some funding from the Canadian Institute of Health Research. So, off we go, we are doing our trial, early on when we were doing the trial.

Jason did a systematic review of all the evidence that was available thus far. The evidence said, “We are not so sure of this radiological healing. There is no evidence at all that anybody functionally benefits from this. Because if your x-ray looks better, and if you cannot walk sooner or have less pain or something like this, who cares if the x-ray looks better?”

We published this in the British Medical Journal (BMJ), this review. The company was not thrilled. In fact, Jason was the first author of this. The company told Mohit, “We want nothing more to do with Jason, get rid of this Jason. He has stabbed us in the back.”

However, Jason was the principal investigator in the study. We were not going to Jettison Jason. So, although, the company did not want in on meetings and so on. Anyway Jason continued to lead the trial. So, usually with these studies, we are committed to go to the end to get as definitive an answer as possible.

We do not go looking at the data partway. However, the company had access to the data part way. They looked at the data. They find nothing good is happening. They say, “Let’s stop the trial.”

So, we fought with them. We managed to continue longer than we would otherwise. However, eventually, they stopped the trial, but not before we would have enrolled 500 patients. That was enough to get a reasonable conclusion.

Then we did not get the complete follow up. Some because they stopped it, but not bad. So, the trial is finished. No benefit whatsoever either on fracture healing or on function in the patients. One of the issues was there was only about 70% or 80% compliance with the device not bad.

What about in terms of what you would expect out in the real world anyway, they obviously did not get the result. So, the first thing, they made all sorts of arguments about how we should present the results.

Either the results said that this compliance was so low, it is not a problem or there is a subgroup that benefits. Anyway, we went through a prolonged discussion about that. We said, “No, sorry, there are not any subgroups who benefit from this device as far as we can tell. It does not do any good.”

So, they tried. They delayed us. They threatened us all with a couple of years between when we would have had to publish and when we published. Because of all their obstruction and so on. Then, of course, they fund going to meetings and say, “Do not pay any attention to this trial and so on.”

But eventually, we published that in the British Medical Journal. In addition, we have another initiative that tries to get ground-breaking evidence that might be practiced, changing out to clinicians as soon as possible.

Then we published one of these rapid recommendations about do not use this ultrasound along with the trial. So, that was an adventure.

Jacobsen: Thanks for the opportunity, anytime.

Guyatt: A pleasure.

We conducted an extensive interview for In-Sight: Independent Interview-Based Journal before: here, here, here, here, here, and here. We have other interviews in Canadian Atheist (here and here), Canadian Science (here), Canadian Students for Sensible Drug Policy, Conatus News, Humanist Voices, News Intervention (here and here), and The Good Men Project (here, here, here, here, here, here, here, here, here, here, and here).

Photo by Owen Beard on Unsplash

Industrialist Basant Kumar Birla passes away

News Intervention Bureau
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Industrialist Basant Kumar Birla passes away

Nonagenarian industrialist and Birla group patriarch Basant Kumar Birla passed away on Wednesday. He was 98. Birla, the youngest son of philanthropist Ghanshyam Das Birla, was born on 12 January, 1921. By fifteen years of age, he was already actively associated with a large number of companies and eventually became the chairman of Kesoram Industries. He also established the Indo-Ethiopian Textiles Share Company, which was the first major joint venture by any Indian industrialist. In response, the Emperor of Ethiopia, Haile Selassie I, awarded him the medal of the Order of Menelik II, the highest Ethiopian award.

In April 1941, he married Sarla, the daughter of activist and writer Brijlal Biyani, after having been introduced to each other by Jamnalal Bajaj and Mahatma Gandhi. They had a son, Aditya Vikram Birla, and two daughters, Jayashree Mohta and Manjushree Khaitan.

He was the chairman of the Krishnarpan Charity Trust, which runs an engineering college named BK Birla Institute of Engineering & Technology in Pilani, Rajasthan, the Swargashram Trust, which administers a Sanskrit school in Rishikesh. He also established Birla Public School in Qatar and the Birla College of Arts, Science & Commerce in Kalyan near Mumbai. He is the author of several books, including an autobiography entitled Svantah Sukhaya.

Ranjit Singh: The Great Maharaja of Punjab

Jaibans Singh
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Ranjit Singh: The Great Maharaja of Punjab

Maharaja Ranjit Singh, the most prominent Sikh ruler in history, was an exceptional human being who achieved great heights and glory. A true disciple of the Sikh faith, he fulfilled the ideological aspirations of his master, Guru Gobind Singh Ji, by breaking the barbaric stranglehold of the Afghans and the Mughals on the people of Punjab and creating a liberal and enlightened Empire of the Sikhs. He completed a task that took several centuries and sacrifice of countless members of his community to be accomplished.

Ranjit Singh was born on 13 November 1780 in the house of the great Sikh chieftain of the Sukerchakia Misl, Sardar Mahan Singh, to his wife Raj Kaur. A Misl in those days constituted a loose confederacy that ruled over a designated area in Punjab. At that stage there were twelve main Misls of which five were the most powerful; these were Sukerchakia, Kanhaiya, Nakai, Ramgarhia and Bhangi Misls.

The Sukerchakia Misl had been built to a strong and dominant position in Punjab politics of those days by its founder Sardar Charat Singh, the grandfather of Ranjit Singh and by Sardar Mahan Singh, the father of Ranjit Singh. The Misl controlled lands between River Ravi and River Chenab which now fall in Pakistan. The capital of the Misl was Gujranwala a strategic hub north of Lahore and the area from where the Afghan raiders came into Punjab. Lahore and Amritsar were with the more powerful Bhangi Misl and the area to the Eastin Majha (Fatehgarh Curian, Batala, Gurdaspur) was with the Kanhaiya Misl. Nakai suzerainty was to the south-west in the general area of Kasur. Ramgariah, Ahluwalia and Singpuria Misls were more into the Doaba region.

Ranjit Singh, whose birth name was Budh Singh in his childhood, was afflicted with Chicken Pox that left him scarred and without one eye. The affliction neither reduced his confidence nor came in the way of his military training. The times were such that he did not get the luxury of a formal education, but he did learn the Gurmukhi script. He was, as such, adept in martial arts as well as reading of the Sikh scriptures. A born horseman and military strategist he fought his first battle alongside his father at the age of 10.

Mahan Singh was very close to the Kanahaiya Misl chiefs but a dispute arose over money matters. He aligned with the Ramgarhia Misl to destroy the Kanhaiya Misl and in the ensuing Battle of Batala in February 1785, the next in line of succession in the Kanhaiya Misl, Gurbaksh Singh Kanhaiya, was killed. Sada Kaur, the wife of Gurbaksh Singh took over the leadership of the Kanhaiya Misl. A brilliant strategist, she did not take long to realise the benefit in putting the old enmity with the Sukerchakia clan aside for the sake of garnering power and ensuring survival of her people. She met Raj Kaur, the mother of Ranjit Singh in 1786 at Jwalamukhi and the two ladies decided upon marrying their respective children, Ranjit Singh and Mehtab Kaur (both below ten years of age at that time) to dispel the enmity.

The early indoctrination of Ranjit Singh into the affairs of the Misl paid good dividends since he was called upon to take the responsibility of a chieftain at a very young age. Sardar Mahan Singh died of dysentery in April 1790 and young Ranjit, barely ten years old, found himself anointed as chief of the Misl. The early days of his chieftainship were under the regency of his mother Raj Kaur and the able minister Dewan Lakhpat Rai. The marriage of Ranjit Singh and Mehtab Kaur took place in 1795, after which, his mother-in-law, Sada Kaur became one of his principle advisors.

In 1798, Ranjit Singh went into yet another strategic alliance through marriage with Raj Kaur (renamed Datar Kaur after marriage) daughter of Sardar Ran Singh Nakai, the chief of the Nakai Misl. She went on to become the mother to the heir apparent, Prince Kharak Singh, and was addressed a Maa Nakian. Allthrough her life, she remained a favourite of Ranjit Singh from among his 20 plus wives.   

The territory of Sukerchakia Misl was the first to come in contact with an invasion coming from Afghanistan. Recognition as a warrior came the way of Ranjit Singh when he defeated the forces of the Afghan ruler, Shah Zaman, over two years in 1797 and 1798. Buoyed with this success and flush with the combined power of his own and the Kanhaiya Misl, Ranjit Singh annexed Lahore and drove out the Bhangi rulers in 1799. At that stage Ranjit Singh, by amalgamating the territories of the Sukerchakia, Bhangi and Kanahiya Misls controlled what is known as the Majha region, inclusive of areas that are now in Pakistan. Jammu ceded by default in 1800.

 In 1801, Ranjit Singh, at the age of 21, proclaimed himself “Maharaja of Punjab.” He termed his rule as “Sarkar Khalsa” and stuck coins in the name of Guru Nanak. His anointment was done by Baba Sahib Singh Bedi – a descendant of Guru Nanak.

On April 25th, 1809, Maharaja Ranjit Singh and the British entered into a pact, known as the Treaty of Amritsar, to define their relations. The Treaty prevented Maharaja Ranjit Singh from expansion south of the River Sutlej but alongside gave him full liberty to gain control of the areas north of the Sutlej. By then the Sikh Empire had already taken Kasur. Within a decade, Multan and Kashmir accepted Sikh suzerainty. The battle with Afghans were many and ferocious, fought mostly by the able Generals of the Maharaja, Dewan Mokham Chand and Hari Singh Nalwa.

Absolute victory came the way of the Sikhs in November, 1819, when the Afghan ruler Dost Mohammed accepted the sovereignty of the Maharaja over Peshawar along with a revenue payment of rupees one lakh a year. The victories of Kashmir, Peshwar and Multan were celebrated by naming three newborn Princes after them. Prince Kashmira Singh, Peshaura Singh and Prince Multana Singh were born to Daya Kaur and Ratan Kaur, wives of Ranjit Singh.

The geographical reach of the Sikh Empire under Singh included all lands north of River Sutlej right up to Afghanistan. The major townships in his empire were Srinagar, Attock, Peshawar, Bannu, Rawalpindi, Jammu, Gujrat, Sialkot, Kangra, Amritsar, Lahore and Multan.

Maharajah Ranjit Singh was the first Asian ruler to modernise his army to European standards. His armies achieved great military feats and victories because of their training, discipline and professionalism and most of all, unquestioned loyalty to the Maharaja. They were composed of soldiers and Generals of all communities (Sikhs, Hindus and Muslims) and were trained by European officers who had served with Napolean. Special training was imparted to infantry and artillery on their being equipped with modern rifles and guns. 

Maharaja Ranjit Singh, though only informally educated himself, was very particular in running an efficient and well tuned administrative machinery. He was well known for filling the administrative positions with men of various religions selected purely on basis of their merit.  After carefully selecting his ministers he delegated responsibilities and then kept a close eye on affairs of state personally. The system of relying on verbal orders was replaced with proper documentation.

The Sarkar Khalsa established by Maharaja Ranjit Singh was one of the earliest examples of seamless secularism. The Maharaja never forced Sikhism on his subjects; he, in fact, showed tolerance and respect towards their religion and participated in their practices and festivals. This was in sharp contrast with the attempted ethnic and religious cleansing of past Muslim rulers. As a result, the Muslims who formed a majority of his subjects, were intensely loyal to him. Thus, Ranjit Singh created a state based upon the noble tenets of the Sikh Gurus which enjoined people of diverse backgrounds to live together in peace and harmony.

While being a benevolent and liberal leader, Maharaja Ranjit Singh personally remained a devout Sikh. He was responsible for the Gold Plating of Sri Harminder Sahib, in Amritsar. Being a devoted disciple of the tenth master of the Sikhs, Guru Gobind Singh, he built Takth Sri Patna Sahib, the birth place of the Guru and Takth Sri Hazur Sahib, where the Guru left his worldly body. Both the Gurudwaras’ are sacred for the Sikhs. He took upon himself the responsibility of construction and maintenance of many other Gurudwaras’ within Punjab and in other parts of the country. He is also said to have donated large sums of money for Hindu temples and other shrines.

Ranjit Singh was a great fearless warrior, able administrator, statesman and a noble King. He was a liberal ruler; despite being an absolute monarch he was democratic in his thought giving credence only to attributes of merit and loyalty. He dedicated his reign to the Khalsa and never wore a crown, his court was splendid and his jewels extraordinary but personally he liked to remain simply attired.

Maharaja Ranjit Singh is a towering figure in Indian history. He epitomises all qualities espoused by his Gurus which also form the basis of enlightened Indian thought and philosophy. He is a national icon and a role model in leadership, nobility, nationalism, tolerance, professional proficiency and other such qualities. There is every reason to be proud of this great son of India.

‘Ramayana tourism’ to be popularised in the country

News Intervention Bureau
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‘Ramayana tourism’ to be popularised in the country

Religious and cultural tourism in India has always been an attractive thematic area. To further popularise it, government is now developing a Ramayana Circuit.  Information in this regard was shared by the Minister of State (I/C) of Ministry of Culture and Ministry of Tourism, Prahlad Singh Patel in reply to a question in Rajya Sabha.

Ramayana Circuit is one of the fifteen thematic circuits identified for development under the Swadesh Darshan scheme of Ministry of Tourism. Fifteen destinations have been identified by the Government for development of tourism under the Ramayana Circuit The Ministry has initially identified destinations including Ayodhya, Nandigram, Shringverpur & Chitrakoot (Uttar Pradesh), Sitamarhi, Buxar & Darbhanga (Bihar), Chitrakoot (Madhya Pradesh), Mahendragiri (Odisha), Jagdalpur (Chattisgarh), Nashik & Nagpur (Maharashtra), Bhadrachalam (Telangana), Hampi (Karnataka) and Rameshwaram (Tamil Nadu).

The projects for development under the scheme are identified in consultation with the State Governments/Union Territory Administrations and are sanctioned subject to availability of funds, submission of suitable detailed project reports, adherence to scheme guidelines and utilization of funds released earlier.

Left Wing Extremism weakening in the country

News Intervention Bureau
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Left Wing Extremism weakening in the country

The grip of Left Wing Extremism (LWE) in the country has weakened significantly. It came out in the review meeting called by Union Home Secretary Rajiv Gauba with Chief Secretary, DGP of affected states, DIB and DGs of the CAPFs.

It was noted that there has been a consistent decline in violence and considerable shrinkage in geographical spread of LWE in the last 5 years. The review of LWE affected districts in 2018, resulted in reduction of SRE districts from 126 districts to 82. However 8 new districts have been added to the list as a pre-emptive measure.

A detailed exchange of views took place. Useful suggestions and security concerns by the States were taken note of. Making mobile communication more effective and improvement in the working conditions of the security forces deployed in the LWE theatre were also discussed.

It was decided to carry forward the resolute implementation of National Policy and Action Plan to address Left Wing Extremism – 2015

Union Home Secretary appreciated the efforts of States and the Central forces. He further mentioned the need for continued operations and stressed upon filling up of areas of security vacuum. He assured that resources required in the endeavour, shall be provided to States and CAPF.

New Delhi is addressing Kashmir with clarity and confidence

Dr Simrit Kahlon
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New Delhi is addressing Kashmir with clarity and confidence

Union Home Minister, Amit Shah, chose to visit Kashmir before his maiden address in Parliament. Apparently, he wanted to get a grip of the situation on ground before speaking. He sat through a detailed briefing on all political, social and security aspects with emphasis on the current security situation. In his missive to the administration and security forces, while reiterating the government’s policy of zero tolerance to terrorism, he dwelled on giving due importance to putting a plug on the recruitment of local terrorists and removing the disillusionment of the people; he also asked the administration to plug terror funding and enforce rule of law in the state.

In his maiden speech on Kashmir issue, in the Indian Parliament as country’s Home Minister he made three important statements:

“I want to tell people that (the) Narendra Modi government has adopted zero tolerance policy towards terrorism and that will continue.”

“Article 370 is not permanent; we have not changed our stand on it.”

“Whenever the Election Commission says, we will conduct elections in the state. We want to restore peace in the state.”

The policy of newly elected NDA-2 government at centre is based on the twin prongs of addressing and removing disenchantment of people and weaning the youth away from the path of terrorism. Self sufficiency has emerged as the mainstay of development process, more so in the Kashmir Valley.  Gainful employment and empowerment at the grass roots are conduits that have been identified to steer this process to its logical conclusion. To accomplish this the government is willing to go the extra mile, it is now up to the people to also move ahead to avail this very good opportunity.

The military, political and diplomatic misadventures that Pakistan has a proclivity to indulge in are receiving great punishment along the Line of Control (LOC). The Home Minister has asked the Indian Army and the Border Security Force (BSF) to explore ways to completely stop infiltration along the LoC and the International Border (IB).

The remnants of terrorism in the hinterlands of Kashmir Valley are being actively engaged and eliminated despite all odds. Counter-terrorist operations in the hinterland in Kashmir spearheaded by the Indian Army and conducted with complete support of Jammu Kashmir Police (JKP), paramilitary forces and the local populace, have witnessed astounding results. Reports suggest that more than 120 terrorists, including senior commanders of foreign origin have been eliminated in this year itself. The intention of clearing the region of the scourge of terrorism before the end of this year is quite visible. 

When terrorists of local origin come in the dragnet of security forces, people gather into a crowd, pelt stones and interfere in the operation in a desperate bid to save them. The security forces have complete sanction from the government to carry on with their work regardless of this interference. Pressure from the media and other political avenues is not being allowed to play on the minds of the security forces.  Of course, standard operating procedures are in place to keep the locals at bay while ensuring their safety.

In the realm of dialogue the government has, despite pressure from many quarters, maintained a righteous stand of not opening talks with separatist, secessionist and criminal elements on their terms. The Hurriyat has recently attempted to pressurise the government into talks by misleading Governor Satya Pal Malik, but the government sent a firm message that talks can be held only if the leaders of the conglomerate commit themselves to loyalty to the Constitution. This firm stand has taken the wind out of the sails of the duplicitous posturing of the Hurriyat.

On the diplomatic front, Prime Minister Narendra Modi has received great accolades in the recently held meetings of the Shanghai Cooperation Organisation (SCO) and the G-20. He has successfully convinced the world leaders to come together in the fight against terrorism and Pakistan has been universally identified as the chief global sponsor of terror. Pakistan, as such, is becoming quite isolated worldwide as its perfidy gets exposed more and more.

It is heartening to see the government at the centre exhibit such clarity of mind and confidence in dealing with the situation in trouble-torn Kashmir. While, on the one hand, the government has given an open ended sanction to the security forces to eliminate the cult of terrorism and tackle violence and disruption with a firm hand, on the other hand, it is pursuing its development agenda aggressively. Undoubtedly, there is political and social pressure accentuated by a shrill media, but it has not deterred the government from pursuing a well laid out policy and consistent posture with a transparent approach. One gets an impression that the government is quite sure of getting the desired result of ushering peace and development in the trouble torn region sooner than later.

Certain pressure groups within the country and outside are trying their level best to derail the initiative of the government. A sustained campaign is in place to denounce its policy as tough and inflexible. It is for the better that the government has chosen to ignore the diatribe and carry on with its firm, unambiguous and righteous policy which, most importantly, is producing the desired results on ground. The negative campaign which is eliciting great public outrage will die down sooner rather than later. 

Gone are the days when the separatists and the terrorists had their individual space and tremendous support from Pakistan. They worked in tandem with a singular objective of wresting Kashmir from India. The government today has charted a path that meets the aspirations of people by providing to them what they need the most – peace and development. Under the prevailing circumstances, the anti-national and anti-Kashmir forces stand isolated and defeated. An ability to sustain its confidence is bound to reap good results.

Professor Gordon Guyatt on Bleeding in Hospitals

Scott Douglas Jacobsen
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Professor Gordon Guyatt on Bleeding in Hospitals

Professor Gordon Guyatt, MD, MSc, FRCP, OC is a Distinguished University Professor in the Department of Health Research Methods, Evidence and Impact and Medicine at McMaster University. He is a Fellow of the Canadian Academy of Health Sciences.

The British Medical Journal or BMJ had a list of 117 nominees in 2010 for the Lifetime Achievement Award. Guyatt was short-listed and came in second-place in the end. He earned the title of an Officer of the Order of Canada based on contributions from evidence-based medicine and its teaching.

He was elected a Fellow of the Royal Society of Canada in 2012 and a Member of the Canadian Medical Hall of Fame in 2015. He lectured on public vs. private healthcare funding in March of 2017, which seemed a valuable conversation to publish in order to have this in the internet’s digital repository with one of Canada’s foremost academics.

For those with an interest in standardized metrics or academic rankings, he is the 14th most cited academic in the world in terms of H-Index at 240 and has a total citation count of more than 247,000. That is, he probably has among the highest H-Indexes, of any Canadian academic living or dead.

Scott Douglas Jacobsen: When it comes to some of the issues with regards to bleeding in hospitals, what are the forms of being in hospitals that you have looked into?

Distinguished Professor Gordon Guyatt: The main areas that we have explored have been two major ones. One is bleeding related to surgery and the other is bleeding in the intensive care units. So, those are the major ones. The bleeding, the bleeding in surgery, has been the reason we have been interested in it because it is related to prevention of thrombosis.

There are two major forms of thrombosis. One is in the venous system. So, the veins that bring blood back to the heart. Clots in the veins in the legs is a common problem. It is a problem when people sit around and do not move. So, it is a post-surgical problem. As a result, it has been now routine in many forms of surgery. Any surgery that involves prolonged mobilization of any sort to give anticoagulants or anti-platelet agents.

Anticoagulants, the clotting system platelets are a little thing circulating in the blood that get the clotting process started and drugs like aspirin inhibit the platelets. Then we have anticoagulants that inhibit the clotting system.

So, we give these to people around surgery to prevent clots, but, unfortunately, anything that prevents clots causes bleeding. We also are worried about clots on the arterial side, so the most awful consequences of clots in the arterial side are strokes.

So, lots of people, lots and lots of people, around the world are using medication to prevent clots on the arterial side. People prevent it. People with heart attacks are, sometimes, using three medications to prevent clots. People who have strokes are using anti-platelet agents to prevent further strokes.

So, there are lots of people walking around taking these things. All of them increase bleeding. In the peri-operative setting, when people come into hospital, they are taking these medications to reduce thrombosis clots on the arterial side. The question is, “Should they continue through surgery or should they not continue through surgery?”

So, I have been involved in work around this tradeoff between bleeding and clotting in patients undergoing surgery.

Jacobsen: Canada has an older population than many places in the world. How does this factor into that as a consideration? People as they get older are more likely to get surgery.

Gordon Guyatt: Yes, a couple of things. First, Canada has an older population than developed countries, but they are compared to what are called developing countries or low income countries. However, it has a younger population than, for instance, Japan and Europe.

So, we are far from the oldest of the oldest. However, our populations have been getting older. People are living longer. Lifespan is increasing. Not only older people need more surgery, but we are doing surgery on older people than twenty years ago.

We would not have been doing surgery on them, simply because we would have said, “Sorry, you are too old. We almost, almost can do it.” It is rare that we say, “You are too old to anybody now.”

We are certainly doing surgery on people in their 90s. We would not have been doing that before. So, we do not turn down people who need surgery because of age much anymore. So, and clearly, the older you are, the more you are at risk of bad things happening, be they clots or bleeding.

Jacobsen: So, when it comes to the types of medications, what are some of the standard medications? What are some of the risks associated with that?

Gordon Guyatt: Commonly, aspirin is a good agent for decreasing clotting, but it is also a good agent for increasing bleeding. So, that is one. Then there is another class of drugs. Another class of anti-platelet agents, of which examples are Lipitor.

These are even more potent anti-platelet agents than is the aspirin. Then there are anticoagulants for many years’ including Warfarin or Coumadin. It was the only anticoagulant around. But in the last decade, we now have a whole army of new anticoagulants that have a major advantage from warfarin.

You needed to check the level of anti-coagulation in the blood all the time, regularly. With these new anticoagulants, you do not have to do it. You can check it. So, they have these convenience antigens.

So, these are the major drugs we are using in terms of preventing clots but causing bleeding.

Jacobsen: What is the statistical difference when someone does use an anticoagulant as opposed to when they do not – or at least when you use different ones over another or none? What are the comparative statistics in terms of the bleeding rates that would be a concern?

Gordon Guyatt: So, typically, anti-platelet agents increase or individually increase bleeding less than the anticoagulants. However, if you are taking two of them together, you are getting to a bleeding risk that might be similar to the anticoagulants.

Jacobsen: Okay, where you are going to be taking this research at present or in the future?

Gordon Guyatt: Oh! It is interesting. All sorts of things are interesting to us. It might not be interesting to other people. But one thing, there has been a huge evolution in the way people have been treating patients around surgery.

We are mobilizing much less quickly. So, this has been most dramatic in the case of hip and knee replacements, where people usually sit around. They gave them plenty of time to develop nice clots that would kill them, when the clots develop in the leg. Then they break off into the heart, into the lungs.

But the mobilized surgical technique is getting better. Now, we are getting more people out of bed right after their surgery getting them to walk around as soon as possible. It has markedly decreased the risk of clotting after surgery.

So, this question, “Do we need any of this?” So, for instance, the standard is to give an anticoagulant for up to a month after a hip replacement. However, it is not at all clear that this is necessary anymore. As a matter of fact, I am getting a hip replacement. I am going to walk.

I expect to be getting out of bed and walking around on day one. If I am lucky, I want to use an anticoagulant, aspirin, which is less effective against clotting but also causes less bleeding.

I am going to talk to my surgeon, but I am going to be using aspirin. So, because I am going to get myself up, it hurts, but I am going to walk. I am going to decrease my risk of clotting. So, that is the evolution of what is happened around surgery.

So, it is changing the way we think about things.

Jacobsen: I want to give a decades long perspective or even half century perspective to people reading this.

Gordon Guyatt: 50 years ago, people would die of their clocks. Maybe, it was same after heart attacks. Maybe, going back 60 or 70 years, we used to think it was all you. I had a heart attack. You better rest, you better stay in bed for a while. Anyway, the result was people developing all these clots and dying on their Venous Thromboembolism (VTE).

Then we decided that is not such a good idea. Now, we are getting people up. We can even be more aggressive in getting people up than we have it now. We do not have people sit around. Then maybe 40 years ago, people were still sitting around longer than we would think reasonable now.

People said, “Okay, we are the people developing all these clots. We better prevent them.” Then all of the prevention strategies came in. Now, we are saying, “Okay, got people out and maybe, we do not have to be so aggressive about preventing the clots as mobilizing. They will decrease.”

Jacobsen: Now, you gave a side comment there. You would be more aggressive. Ideally, what would be moving your most aggressive stance in terms of getting people out?

Gordon Guyatt: I am not sure. I am not sure that we cannot have people walking around the wards on the same day; they are having their heart attack, but, maybe, that is being too, maybe, aggressive.

Jacobsen: What would be a response from someone within the field to that recommendation?

Gordon Guyatt: Oh my goodness, you are having a heart attack. Please give the person a day’s rest anyway.

Jacobsen: Let’s project this project this 10 year forward, it is with things that you would know better than most of people, in terms of whether it is a new set of drugs or new evidence in terms of practice. For example, we can take on board: same day getting up, for instance, after a heart attack. What would things look in 10 years from now? Approximately.

Gordon Guyatt: It is difficult. We get surprised. So, I do not know what is going to happen in terms of drug development. I am no expert on what is the latest, even now, in what is going on in drug development.

So, a small thing that we are thinking now. One of the trials we would first is asking the question, “Do you need any anticoagulants at all?” However, if you are going to give it the traditional methodology, you would give it right after surgery.

However, the big bleeding risk is in the 48 hours after surgery, maybe 72 hours, the first day. The most in the second day, after that, the bleeding risk falls off. But the thrombosis risk goes on for a month.

So, if you are going to give anti-thrombic agents, maybe, you should wait for a couple of days before you start. On the other hand, maybe, those days are crucial in terms of setting the stage for clots that happen later.

We do not know. So, that is one of the things that I would want to sort out if you are going to use anticoagulants in surgical situations that are higher risk. When should they start? So, perhaps, one way is to view it as a trivial question, but, potentially important, in terms of minimizing bleeding risk while still getting the benefits of clot reduction.

Jacobsen: Thank you for the opportunity and your time, Professor Guyatt.

We conducted an extensive interview for In-Sight: Independent Interview-Based Journal before: here, here, here, here, here, and here. We have other interviews in Canadian Atheist (here and here), Canadian Science (here), Canadian Students for Sensible Drug Policy, Conatus News, Humanist Voices, News Intervention, and The Good Men Project (here, here, here, here, here, here, here, here, here, here, and here).

Photo by Chris Mai on Unsplash

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