Distinguished Professor Gordon Guyatt 1

Author(s): Scott Douglas Jacobsen

Publication (Outlet/Website): In-Sight: Independent Interview-Based Journal (Unpublished)

Publication Date (yyyy/mm/dd): 2020/02/03

Scott Douglas Jacobsen: Let’s start on a positive note for 2020 based on something that I missed in the news reportage for you. You were inducted into the Hamilton which is a place in Ontario, Canada, Hall of Distinction or Gallery of Distinction. What was their reasoning that they gave behind it and what was some things that happened at the ceremony, if there was a ceremony?

Gordon Guyatt: It was, I think a recognition of my research contribution to McMaster University and thus the contribution to the Hamilton Community and the most interesting thing was that a fellow inductee was the Vice Principal at Westdale high school when I was a student. His contribution was a contribution to the Arts at Hamilton and I don’t know what more he did but when I was a student at Westdale, he had written a Musical called ‘Swerg’ in which one of my very good friends was the lead actor and this was a quite memorable high school event.  There was Gordon Carruth, who was the vice principal who wrote the musical there, as a fellow inductee into the Gallery of Distinction for his contributions to the artistic community. So, it was kind of fun. Usually, they have probably people from 50 to 90 as the inductees but at the age of 66, I was the junior inductee, everybody else was quite old and I found it sort of cute, it was fun.

Jacobsen: What does Swerg mean?

Guyatt: Nothing, it was the name of the lead character.

Jacobsen: Okay. 

Guyatt: This event happened about 50 years ago, that’s my memory of it, that it was the name of the lead character. It was quite memorable, I mean 50 years ago is a long time, it was quite a memorable event.

Jacobsen: Have there been any other awards or recognitions since that last one that at least that I’m aware of?

Guyatt: No, nothing else since that one.

Jacobsen: I think last two times we’ve talked; we’ve talked about the meat study and that was what you called a predictably hysterical in many of the responses along a gradient to just inflammatory and that has been rolling out some news item things along.

Guyatt:  Yeah, it’s still reverberated. I just did an interview about it yesterday.

Jacobsen: There you go. So, one thing that I think was interesting or two things; on the one hand in the journalistic world and then on the other hand in the academic world. So, I want to cover those separately. I’ll start with the first one mentioned for the journalistic world, the New York Times did an article and they were, I’m not sure if it was gotcha journalism at the level of the New York Times, but it was certainly looking for a dig at the reputation of at least one of the researchers in the meat studies. That had to do with, I believe, a financial conflict of interest stated about one of the authors. In some other commentary, it was noted that one of the nuances was missed in some of the other journalistic commentary that of the 14 people who, I think were accepting of the recommendations, three were dissenting.

So, let’s start on the first point there to deal with the individual claim about financial conflict of interest. Most did not have any. Of those that might have, what were some of the concerns that were brought forward in in some of the commentary that you’ve noticed?

Guyatt: Well, the individual who had what could be perceived to be a financial conflict of interest had received 50,000 bucks to do a study of guidelines related to sugar. And this money came from something called the International Life Sciences Institute which is contributed to by, I’ve been told 400 companies or must be in that vicinity of which a few have connections with the meat industry. So, you can judge that for yourself how much that constitutes a conflict with the guidelines about red meat. 

The other was that Brad Johnston, the individual in question had been recruited from Halifax, Dalhousie, where he was currently or until recently was a faculty member to Texas A&M which is a university in Texas. When he had been recruited, he got some startup money. This startup money, he had thought was from the University but as it turned out, a small part of it was from another sort of Institute called Agrilife who receives 40% of its money from Industries related to plant-based food and 1.5% of its money from the meat industry. He was unaware at the time the red meat work was going on, that part of his money was coming from Agrilife. In terms of declarations of conflict of interest, there’s often a three-year time frame that is people say “Okay, after three years we’ll not worry about it anymore,” and the illicit money that Brad received was more than three years before the red meat work.

Jacobsen: For those that aren’t aware of how some of the COIs are dealt within the academic system, including myself in full, what’s the scaling or gradient of what’s considered severe, moderate, minor; in terms of COIs or is it not even really a COI?

Guyatt: So, one question is to what extent is it related. One of the things that there are lots of gray areas, so for instance, Brads would be in the, I would have described, in the gray area. So, you receive money from a group of 400 companies of which a handful are related to the meat industry. Is that a conflict of interest for a meat guideline? One could argue it either way. Some people would make the distinction between the money you receive that goes in your pocket versus money that you receive to do a research study. And again, this other one where money contributes to startup funds. Again, not personal income where 1.5% of the money comes from some people connected with the meat industry. So, this would contrast for instance from you received $100,000 in personal income from a manufacturer of a drug; that is the topic of the guideline, that would be another extreme of what one might say. So, there’s clearly gradients of seriousness of the conflict of interest. 

So, you receive money to go to a meeting where from a company related to a guideline that you are on this would be another, so the ones that would be unequivocal would that substantial money goes into your pocket from a company that is producing a drug that is the topic of the guideline. Everybody would agree that this is probably not… This would definitely be an unequivocal conflict and then sort of things that happen to Brad is clearly, if they are financial conflicts, they’re less serious.

Jacobsen: Of the 14 opinions given, the three dissenting; what were their justifications for dissent? 

Guyatt:  What the grade criteria for a recommendation, where are the balance of benefits… two ways to put it; where are the balance of benefits and harms, burdens; where does it go? In favor or against a particular course of action? Or another way to put it which I like and when I’m chairing panels I direct them in this way, which is; if you had a thousand people who were fully informed, what choice would they make? Let me ask you, the situation is that you have what we call low quality evidence meaning that causation remains uncertain. We have low quality evidence that if you reduced your meat consumption by three servings a week and you did that for the rest of your life, you would reduce your risk of dying of cancer by 7 in a 1000. Similar sorts of reductions perhaps in potential, although uncertain because of the low-quality evidence in cardiovascular disease.

Now, so that’s the situation. Situation is an uncertain, what most people would consider small, perhaps very small health benefits by reducing your meat consumption by three servings a week for, our time frame for cardiovascular disease was a decade and our time frame from cancer was lifetime, and you take a thousand people in the population who are eating meat. Of those thousand, given disinformation, how many of them do you think would reduce their meat consumption? What do you think?

Jacobsen: Very few. 

Guyatt: So, the opinion of the majority of the panel was that that a minority for sure would reduce. However, the opinion of those three people was would be that a majority faced with this would reduce the meat consumption. I mean we did a systematic review of people’s values and preferences related to me in a what’s been what research has been conducted, which is a lot of people like their meat and it’s a cultural thing and they wouldn’t know how to prepare a meat meal, they couldn’t put meat in it and so on. So, we had some evidence about people’s attachment to their meat consumption. It’s a matter of opinion as to where the balance goes and for those three people the balance went, I think probably slightly in the other direction.

Jacobsen: Just a small note on that response; the great approach has this high, medium, low, and very low in terms of quality.

Guyatt: The quality of evidence is high, medium, low, and very low. The evidence reporting the adverse health effects of the meat was low or very low. We looked at all sorts of cancers and heart attacks and diabetes and so on. We looked at a whole bunch of health outcomes putatively adversely affected by Meat consumption and the evidence was either low or very low.

Jacobsen: And some looking at the commentaries of prior research, current research, or some of their reactions. The important thing that I think as a commentary on evidence-based medicine and part of the reason for the controversy around the red meat study is that the way evidence-based medicine does things is fundamentally different than what has been done before and then the way things are done in probably a bunch of other areas in medicine in terms of doing these kinds of analyses. So, people looking at in the public, they’re getting from their perspective contradictory opinions on health. So, maybe you can clarify some of the muck there.

Guyatt: The methods of our systematic reviews were not very different from the methods of people who’ve done systematic reviews in the area previously and the results were not very different. So, the increase, if you take it in relative terms; the increases in the adverse health outcomes were between 10 and 20% as a result of meat which was very similar to what other people had found. The differences were in the interpretation. So, the nature of the studies, and we’ve talked before about observational studies I could go over it again, but the nature of the studies were not studies that in our view that allow high quality evidence or even moderate quality evidence. Other people had interpreted this literature as stronger or more compelling evidence of adverse effects of causal effects of red meat than did we, that was one thing.

The second thing was that people had previously not pointed out that even if there was causation going on here that the absolute effects were small or by many people’s reckonings; very small. So, it was not that the methods were drastically different or the results were drastically different, it was the way of looking at the results and interpreting them that was different.

Jacobsen: Now some names are coming to mind. Do you want names in print?

Guyatt: Sure, it doesn’t bother me.

Jacobsen: Okay. So, this leads to some would say reasonably prestigious institutions like Harvard. The current president, Lawrence Bacow but in particular one Professor Frank Hu.

Guyatt: And the biggest name Walter Willet.

Jacobsen: Yes. So, if we take Hu as an example; he was leaning more on observational studies as a counter to some of the presentation and reinterpretation of the evidence.

Guyatt: Three out of our five systematic reviews were exclusively observational studies which as I say, our results didn’t differ very much from previous reviews of the same topic. We were more thorough, we got all the literature, and various things we did that we thought improved but the results were very similar.

Jacobsen: And I have other researchers like Frank or Walter Willet; will have they by and large been in agreement as things have moved forward?

Guyatt: I don’t think within the observational studies, the criticisms have not been of our methods or our results, the disagreement has been over the inferences. The disagreements have been over the what one says the quality of evidence is. They would say I suppose, they tend not to use the same terminology but they say the causation is established and we say with the evidence that is before us, it’s only low certainty evidence and the causation is not established. So, that is one disagreement. I think they’ve stayed away from the absolute effects altogether but when people have taken us on about the absolute effects, they take a population rather than an individual perspective. If you look at the science, there is a legitimate disagreement about what inferences one can make from these observational studies and I could talk about why we think one can make only weak inferences, why we call it low-quality evidence. They think you can make stronger inferences. Oaky, that’s a legitimate scientific disagreement.

There’s another disagreement on perspective. So, we very specifically said we are taking an individual perspective and that’s what I just described to you. So, I described to you what our interpretation of the evidence and the magnitude of effect and I asked you in a thousand people how many people faced with that would reduce their red meat and that was the perspective. Now, if you took that seven in a thousand reduction in a lifetime of cutting your meat consumption by three servings a week and you said what would happen first if it was true that you could reduce your likely to have cancer in relative terms by 15% say over the course of your lifetime. Let’s say that was true and then you said that all 350 million people in the United States reduced their red meat consumption by three servings a week, you’d now say reduce 10,000 deaths a year or something. They say “How can you call 10,000 reductions in death in a year a small effect?” 

You seem slightly amused but this is a legitimate alternative way of looking at it. We look at it at an individual level and they look at it as a population level and those are different perspectives. So, there’s two and I think they both have their legitimacy. We think that the people who spend their lives in public health say “Let’s look at the population and let’s tell everybody what to do according to our view of what’s good for the population.” We say these things should be decisions by individuals and you shouldn’t be telling them what to do when they themselves faced with the decision would make a different decision. That’s a different perspective. So, there’s these two differences in perspective; one being how certain can we be about that this is really a causal effect of approximately this magnitude where we say we can’t be certain at all and they say they can be certain or pretty certain or maybe certain. 

So, that’s one thing and secondly do you take it individual perspective or you take a population perspective. These are the legitimate disagreements but those legitimate disagreements if responded to appropriately would not lead to the excessively dogmatic indeed hysteria that accompanied our guideline and with its underlying perspective that I’ve just told you about.

Jacobsen: I think that covered the main aspects of both the journalistic side and some of the academic side of things. 

Guyatt: I apologize but I just thought I was talking about the academic [Laughs].

Jacobsen: Well, we’ll cover both. I think with the one sending opinion to do with Agrilife and the 1.5% being shuttle off to the meat industry of the few out of 500 companies; that particular one was the journalistic focus from The New York Times. There was kind of peripheral commentary as well around some similar things not as well written. And then when it came to the academic side, there was people like Frank Hu and some others who were basically taking what you were saying just now, taking those different perspectives; population, individual, etc. There was another that I had missed before to do with evidence-based medicine and that was Gøtzsche. What happened with this person? 

Guyatt: What happened to this guy is, there are people in the world who kind of enjoy upsetting people, it’s always dangerous to attribute motives but, who do go about upsetting people. And when they make statements, they do so in an inflammatory way and they’re attacking people and so on. There’s an organization called the Cochrane collaboration. Cochrane collaboration has been around for over 20 years now and its mission is to summarize all the systematic reviews known to humankind and it’s doing pretty well. After 20 years it’s summarized over 5,000 reviews. Peter Gøtzsche was one of the founding members of the Cochran collaboration and he was elected to its, I don’t know if it’s steering committee or board of directors something like this; the group that’s sort of in charge of directing the organization which has about 15 members or so. And in this position, he said that the Cochrane collaboration has gone awry and is serving industry interest where it should not be and he particularly attacked the CEO of the organization on these grounds.

He then also attacked specific Cochrane reviews saying these Cochrane reviews are very misguided and misleading and so on so forth. There was no subtlety about the way he did this at all and I think he was driving some members of the executive; he was driving them nuts with these attacks and the CEO was very upset at him and you can imagine the conversations that went on behind the scenes about this. So, they decided they were going to, for the first time this has ever happened in their over 20-year history, they were going to decide to eject him from the board or the executive and not only that but eject him from the organization so that he would be excommunicated and thrown out at the Cochrane collaboration. The board was split on this and four members of the board passed in a close vote, they passed the resolution to throw him out. Those who were dissenters were told that they had a choice to keep their mouth shut and do not publicly dissent or resign; and they chose to resign.

I sympathize with the people who found Peter Gøtzsche’s behavior difficult to tolerate. He is as impolitic as one could get and he spares nobody’s feelings. So, it’s not pleasant. I can understand that people finding it hard to tolerate. However, we’re a scientific community where you have some people who don’t behave in a very nice way but all the positions that he raised were defensible positions. He raised them in ways that people felt was that he was undermining the organization. So, telling people that the organization has gone off the rails and the CEO is behaving badly and they’re producing reviews that are very problematic; indeed, that does not help the reputation of the organization when a member of the board is saying such things but they were all defensible statements. So, I can understand people being upset about this but we’re supposed to be a scientific community that tolerates freedom of speech. So, some of us while understanding that what he was doing was in ways undermining the organization, we can’t throw the guy out when the statements that he’s making are defensible statements even if his style of making them is problematic.

Jacobsen: That’s fair, I mean it’s a parathentical statement. I remember I was coerced into resignation from a board and they’re like don’t talk about this and you’re just like all right.  

Guyatt: Well, some of us would say that what the board did was really stupid. First of all, to throw the guy out; it would be predictable that there would be in many people outrage over this behavior of throwing the guy out. To do it when it was a close to a 50-50 split, as to whether he should go out and then to tell the people who were dissenters that they either resign or adhere to cabinet solidarity if you will. It must have been driven by intense frustration and anger at this God but they let their frustration and anger get the better on them in terms of a judicious way to deal with the problem.

Jacobsen: I’ve seen it where it’s like the CEO didn’t even, this isn’t the organization which we meant right now but maybe at some point in the future, but it’s like they cooked up and exaggerated things. There was no vote, it was a singular decision and then everyone was silent. There was assemblance of a procedure here in the one that you’re saying here, right?

Guyatt: Oh yeah. It was an assemblance of procedure, it was a clear but probably misguided procedure.

Jacobsen: Within the medical community and among the best positions to probably have an opinion on this, just given the height of your career and the length of your career; what are the political difficulties when it comes to boards, interpersonal conflicts, and things like this.

Guyatt: Well, as I said to my colleagues on one of the groups that I was associated with that I was a member of, the executive of this particular group, we had spent an hour talking about interpersonal problems when we would have all preferred to spend an hour talking about science and at the end of this I said “Gosh, if only we didn’t have to deal with people we’d be in great shape.” There’re all sorts of famous controversies within science going back to Freud and some of his original disciples who broke with him and then they’re hurling insults at each other in public and so on. If you read the story of the discovery of insulin, you will find that Frederick Banting did not behave very well with respect to acknowledgement to his colleagues and so on.

Jacobsen: Oppenheimer tried to kill his tutor and that tutor ended up becoming a future Nobel Prize winner.

Guyatt: Yes, and later in his career he was a victim of right-wing individuals who were his opposite, he didn’t think that US should produce the hydrogen bomb.

Jacobsen: Yeah. Einstein was making arguments after the splitting of the uranium atom for the supernational authority, something like the League of Nations there in the UN. 

Guyatt: Einstein wasn’t the sort of difficult guy that Robert Oppenheimer was. Essentially, Einstein was off in his making his various humanitarian statements and so on but he didn’t trouble anybody. Oppenheimer was an effective, he was in the midst of the political battle and an effective guy and they essentially stripped him of all authority and threw him out and so on because of his opposition to making the hydrogen bomb. Anyway, so the science is littered with the sub-tones because scientists are human beings and they operate in a political context.

Jacobsen: One really good case that just dropped out of mind maybe it’ll come back later and it wasn’t quite Oppenheimer trying to kill someone; good but it was okay. I’m thinking of right now Feynman during, I think, one of the Apollo disasters and he had that committee of journalists and scientists and he was showing how just on that rapid temperature change, it can actually snap a certain metal or crack it and that was enough at that kind of velocity when they’re trying to get into lower orbit or beyond. The Challenger explosion; the whole thing just went to pieces. I think there was another case with Carl Sagan and this guy who’s a psychiatrist Russian named Velikovsky wrote this book called World in Collision and basically his whole idea which they called the work of ingenious but ingenious in the sense that it was highly creative nonsense. 

So, the psychiatrist who’s now playing the part of a cosmologist and his whole basis was we’re going to take all of mythology that most people take as mythology and we’re just going to not take it as mythology, we’re going to take it as factual history. So, he had this whole kind of cosmology of the solar system as billiard balls and that that ends up explaining The Parting of the Waters in the Bible and all these sorts of things. And somehow, a solid Planet came out of Jupiter a gas giant and that was the source of all this solar system billiard balls. There’s a reaction to it, there’s New York Times article praising Velikovsky apparently and Carl Sagan’s final commentary or note on all of that, not that it was actually wrong or was bad but the fact that there was an attempt to silence Velikovsky from any kind of sole critique. I thought that was the real crime that it was against to your point earlier about freedom of speech or freedom of expression in Canadian terminology in article 2B of our Charter and it’s just against the [44:45 spirit of dissent and challenge and then counter dissent, counter challenge. When you’re making a big claim, you better have big evidence.

I mean there was some further stuff that came out about P.J. Debra. I think he published some early stuff in late January, I think.

Guyatt: Yeah, PJ is publishing important work on a monthly basis as far as I can tell, as I’ve talked to you before about how impressive what he’s doing.

Jacobsen: Since late last year, are there any major developments in terms of what appears to be his very stunning work as you noting before in terms of having some of those death rates?

Guyatt: So, as I mentioned before, he has demonstrated that he has brought to the four the number of people who proportionately are small perhaps 1.5% who die of cardiovascular causes after non-cardiac surgery but given the volume of non-cardiac surgeries going on, that’s a lot of people dying and that a lot of people are having what are the equivalent of heart attacks after non-cardiac surgery that was not noticed and a lot of those are dying later. So, that was the first thing and showing how to detect those. Now, suggestions that a lot of people may be having minor strokes that we never knew about after non-cardiac surgery, he’s after several studies suggested that drugs that people had advocated to reduce these events don’t work. He found that there’s one drug, an anti-coagulant that does reduce these adverse events after non-cardiac surgery. Those have been major things that have come out of his work.

Jacobsen: Anything in medicine in general that’s going to be drastically changing the field or is it just kind of pretty much smooth sailing for the next little bit?

Guyatt: Well, I mean people talk about the artificial intelligence. I do not think it will drastically change the field.

Jacobsen: Yeah, there’s a financial corporation I worked for in Calgary where I did consultancy with them and CEO keeps talking about AGI a lot. It’s just kind of in the culture, it’s in the Zeitgeist. So, I’m hearing it in medicine, I’m hearing it elsewhere too and I’m hearing a lot more skepticism like it’s going to make things really convenient for us but don’t think it’s going to be as dramatic as people think.

Guyatt: Well, I mean if you say self-driving cars are a result of AI which in a way they are, I suppose; that’s a big event. I think the impact in medicine will be very modest.

Jacobsen: Did you get a copy of the book by Dr. Azra Raza from Colombia?

Guyatt: No, I don’t think so. 

Jacobsen: … She does Myelodysplastic Syndrome research. Her late husband Harvey Preisler who was a cancer researcher as well. Unfortunately, he passed away or died to cancer but she’s been working on this stuff for decade like it’s basically her life work and she’s literally, I didn’t know this about her, been getting samples. She must have I think like 30,000 samples of her own patients in her own storage that she just started doing, just based on kind of an instinct that these probably will be useful later on. She was noting that basically the knowledge about the problem is much greater, implementation not much different and she uses the phrase like slash something and burn; like very emotive words. So, she’s really making a call for is so that people don’t get bankrupt when they go in for a treatment, any kind of treatment or checkup just kind of ordinary people with regular incomes so they don’t have to be completely financially ruined; her terms, not mine. 

So, one thing she did mention around AI was just around the types of scanning technologies, so you can get a slightly better performance than an expert, then you can give that to the AI and it can kind of save them time so that the doctor can work on things that are more pertinent to them, that can’t be automated or at least easily.  And so, a lot of AI stuff that they’re talking about is just really narrow functionality.

Guyatt: It will certainly lead to some efficiencies for sure but I would describe that as relatively modest impact.

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