Magdi Yacoub

Professor Sir Magdi Yacoub, OM, FRS, Founder and President of Chain of Hope, is one of the world’s greatest, and most famous, surgeons. Born in Egypt in 1935, he studied medicine in Cairo and then London, becoming a consultant cardiothoracic surgeon at Harefield Hospital. He first gained international renown there when he established the largest heart and lung transplantation programme in the world. Sir Magdi has a passion for redressing inequalities in global healthcare delivery with a focus on developing cardiac services in Egypt, The Gulf Region, Mozambique, Ethiopia, Uganda, Kosova, El Salvador and Jamaica. He does this as President of Chain of Hope, which treats children from developing countrieschildren with correctable cardiac conditions  and establishes training and research programmes in local cardiac units.

Professor, why did you leave the Egypt of Nasser in 1961?

In those days we were conscious that there were those who had dignity and those who were denied dignity. The medical education in Cairo was brilliant and we loved, almost adored, our professors. There were only 60 people in each batch of students. But Nasser did not appreciate excellence and suddenly opened the floodgates and said that everybody has the right for a university education. We were 60 and we became 1,000, so quality and excellence disappeared. I was hell-bent on becoming a heart surgeon, almost like a blindfolded goat, so I came to England.

Why did you choose to devote your life to the cure and repair of the heart?

There are many reasons, but when I was a young child my Dad was a surgeon, and I liked what he was doing. Then he lost his beautiful younger sister of rheumatic heart disease at the age of 22. He said that this could have been avoided, that there were people treating these valves in the US and the UK, and he had a nervous breakdown. I went to him and said, “I am going to be a heart surgeon,” and although he said, “Don’t talk nonsense, you are not qualified and you don’t have what it takes, which is organisation,” I have never deviated from the idea, and I became a doctor and Sir Russell Brock’s assistant.

You were a pioneer who made one of the first heart transplants?

We are celebrating the 50^th anniversary of the first heart transplant in Cape Town in December next year. Chris (Dr Christian Barnaard) was a lovely man who I knew quite well. The Press picked up on his superficiality, but he also had a very profound aspect to his personality, a deeper, applied scientist. He was poised to do it, even before Norman Shumway at Stanford. It was obviously an idea whose time had come, and I was the first in the UK to do a heart and lung transplant.

You are also famous for research?

I do believe surgery is very important and cures people dramatically, but I believe the actual study of the molecules and genes is paramount. From day one I wanted to discover more. To be more effective at curing children you must know the physiology, how the molecules work together. When I was the first British Heart Foundation surgeon of cardiothoracic surgery I filled my department 70% with basic scientists. People said, “But you are a surgeon.” I said, “I want to do my job better,” and that proved to be very fruitful in the longer term. Now everyone recognises that medicine is multi-disciplinary, and the molecular biology following the human genome projects shows we are all the same and equally we are all different, and that has given birth to the so-called personalised medicine. Without a shadow of doubt this is the future. It helps you to treat people correctly.

Is it really true that 1 child in 100 has a heart condition?

Yes, it is true, and studies show the incidence is even much more in developing countries, where it can be 3%-8% as opposed to 1-2%. And they arrive in a more sorry state, often with malnutrition.

You created a voluntary organisation called Chain of Hope?

Twenty years ago we used to go to treat patients in Africa and South America and then come back, and that was ineffective because you treat very few patients and you don’t know what happens to them. We said, “This is not good enough,” and organised the Chain of Hope with a system, not just to treat patients but to establish new services in neglected areas where they do not have anything.

What made you take on this enormous task?

Somebody has to do it! It is us, because we are professionals and we see suffering first hand. Chain of Hope is a NGO, and while I am the Founder and President hundreds of thousands work at different levels. I have seen children who have nothing and you either offer them something or they die. The Chain of Hope is a chain of people to give hope to somebody that’s hopeless, mothers, parents without hope.

It sounds like a chain of love. What is the aim of Chain of Hope?

We want to make our services available to everybody, regardless of race or creed, with excellence and sustainability. We really have a moral obligation to do something with our knowledge, which has to be applied to humanity, and not to say I am going to pursue science and knowledge and excellence full stop. We aim to continue long after I have gone, and so we have to train people. Human resources are more important than physical resources.

What is your role as leader of Chain of Hope?

I am a multi-tasking dogsbody and I am somebody with a vision. It is like having a fantastic big orchestra and you need a conductor to push the vision. I train people to adopt moral values. I don’t care about skill if they do not have the same ethos. Our ethos is that we are privileged to be able to offer this service. We learn from people and we get massive satisfaction, which makes us better people.

How does Chain of Hope work?

We have a correspondent in the country of origin and we either go and treat the child in the local hospital or bring them to the UK. To be sustainable we establish the physical and human resources in the place – doctors, clinicians, nurses, everything – and we go there and train them. Chain of Hope is establishing capacity in countries such as Jamaica, Uganda, Ethiopia El Salvador and so forth. We train people to do these very complex operations on a 2-3 kilo baby and they do it very, very well. Operating on a child is exacting and requires good post-operative care, they are more tolerant and recover faster but they are not forgiving, any little aberration in their care and they are dead.

How many children has Chain of Hope treated?

Over the last 20 years more than 18,000 children have received treatment in these local centres as well as through the charity’s missions, and International Child Referral Programme. Last year, the Aswan Heart Centre alone treated more than 2,500 patients. As part of Chain of Hope’s work to establish cardiac centres around the world, thousands of children can now receive treatment for heart conditions locally.

What kind of feeling is it to save the heart, the organ at the centre of human lives?

I was fascinated with the heart, I still am, and as time goes by even more. It is the centre of all things, it is life itself, it goes on beating in a coordinated manner without making a fuss. It is so complex in its own right. There are literally millions of molecules working in harmony for the so-called spontaneous contraction, and it responds within fractions of seconds to whatever is thrown at it.

Heart disease and heart attack is still the leading cause of death. How successful is transplant?

The technique itself is not the problem. What’s important is the immune-suppression preventing the body from rejecting the heart. The drugs we have now are much better than those in 1967 when the first transplant was done, but they do not prevent rejection absolutely in the long term, and they produce a hundredfold increase in the incidence of cancer. Having said that, when we started in the 70s and early 80s we never thought people would survive beyond 5 years, at most 10. Now some patients have survived 32 years and are in the Guinness Book of Records. These are people who came into a hospital which was saying they would not survive the night.

There is still a long way to go?

I entitled an article ‘The End of the Beginning’, like Sir Winston Churchill’s saying, “Not the end, not even the beginning of the end, but the end of the beginning.” 20% survive beyond 20 years, a massive achievement, but why have 80% of the patients died within 20 years? That’s a huge figure. I wanted to call my autobiography ‘In Pursuit of Excellence.’ We have not achieved excellence. Just as Nasser broke the excellence of the Cairo medical school I would like 100%. Excellence has been the first obsession of my life. I’m conscious of the incredible inequality in healthcare delivery. There are wonderful discoveries made every day, inspiring things which now benefit only 20%. 80% are disadvantaged. In heart surgery it’s even more.

Who are your heroes?

One of my heroes was the late Sir Peter Medawar, regarded as the father of organ and tissue transplantation. In 1952 he published a paper in Nature, entitled ‘Induction of Specific Immune Tolerance.’ He showed you can do something with cells to stop rejection of an organ or tissue. That led to the development of non-specific immune tolerance with drugs. We still have not realised the dream of Peter Medawar, who defined creativity as simply creating something, ostensibly out of nothing, something of beauty, order and significance. I have adopted his idea to apply what we have learnt to the suffering of humanity in a global fashion.

What is that most significantly determines if you will die from heart failure?

It depends on where you are. The primary need is Percutaneous Coronary Intervention (PCI), because if the patient is rushed to the hospital and you get a heart within 90 minutes and the artery which broke is opened, it prevents the heart attack in 80-90% of cases. If you don’t live within 90 minutes so as to have the artery opened, in 20% of cases you are dead or the heart is damaged beyond repair.

There are not enough of these facilities in the world?

No, emphatically no. My second obsession in life is the massive inequalities in healthcare delivery. In the US, this is terrible, Obamacare is scratching the surface. In the UK the NHS is fantastic, it is the best system in the world. No system is perfect, like transplantation. That doesn’t mean you don’t have it. Compare this with the US where 10 million people have no insurance and die in agony. It’s totally unacceptable.

You studied in the US as well as in the UK. Why did you come back to Europe?

I went to the States because the research is more advanced and there are more different ideas. Just before leaving the UK I was appointed a consultant heart surgeon at Harefield, and that was a good job, so I said to them, “Please allow me to go for a year and then come back.” They said, “No.” I said, “OK, then I am going,” so they asked me to wait outside. Half an hour later they said, “We have given you the job and will appoint a locum for a year.” After a year in America I was offered a tenured professorship in Chicago, which was beyond what I could have imagined. I did not know what to do next.

How did you decide?

I asked a wise colleague and he said, “Listen, you always will take yourself with you wherever you are. Regardless of where you are, you will do what you want, even if you are in the desert. Do not use a score system rationally to decide this or the other, sleep on it.” This is the best advice ever. During sleep your mind continues and then you follow your nose, when your mind and emotions have considered it. I woke up and said, “I am coming back to the UK,” and never regretted it.

What do you perceive to be the main difference between the US and the UK healthcare systems?

When I was in Chicago doing research I was also on-call for emergencies, and someone came in the middle of the night with an aneurism. My students and I worked all night and the patient survived. Four weeks later he was seen as an outpatient, and he was doing great, but then the patient said to us, “I paid $50 to see you and you are 10 minutes late!” I said, “I don’t care about your $50. We worked all night to save your life.” In the US the patient sees that they bought the doctor’s services, and I resent that. That doesn’t happen in the UK patient-doctor relationship.

Did you encounter difficult issues while working in the NHS?

In the NHS I did resign once, because an administrator came to me and said, “You can’t do that,” and I said, “No, I am going to do it.” “But you work for us,” they said. “No,” I said, “I have only two bosses, I serve patients and science.” So they said, “We differ,” and I sent in my resignation. We have to work in harmony together, towards an end which is our target, or it’s, “I am your boss and I tell you what to do.” We have to convince each other so there is no dictatorial behaviour.

Is there a lack of good leadership these days?

I was invited to South Africa four times in one year. I said, “OK I will come if you organise for me to meet Nelson Mandela.” To my surprise they did and I spent an hour with him. I remember he had a picture of Mahatma Ghandi in his drawing room, and he said one thing that I liked very much: “When I was President (he had just retired) at 4pm we had a Cabinet Meeting, and at 7pm I would appear and tell the people what we have agreed.” “What if you had not agreed? “I asked him. He said, “I appear and say nothing. I keep talking until they agree.” “With you?” I asked “No, no,” he said, “until we get a consensus.” That is leadership without being dictatorial.

What is your own leadership style?

Nice, civilised, soft-spoken, but also firm. The line between being nice and being weak is very hazy.

You have a very gentle and soothing voice. Is it the role of the doctor to reassure the patient?

The patient-doctor relationship has to be personal. “Doctor, I trust you, I want you to take care of me.” This relationship has been eroded by both the doctor but also by the patient, and society. To the doctor who sees his job as a technological thing I say, “No, no, no. I see a child , I see a person as a patient.” There is a very special relationship of total trust, much more even than with an airline pilot. I am in charge of an unconscious patient who trusted me totally.

Are you conscious of the need to be strong when you operate?

It’s a massive responsibility. Equally I am a human being. I am emotional, but I must detach my emotions from my intellect, not allowing emotions.

Would you say you are a religious person?

My mother was an Egyptian Coptic Christian, my father was a Protestant. I am very worried about religion for many reasons, most importantly the violence of fighting between them. I believe more in humanity, and I am not religious as such, but I am spiritual.

What does spirituality mean to you?

There is something always unknown, and you have to think beyond what you know. Like Francis Crick, who after discovering the double-helix devoted the rest of his life to the mechanism of consciousness. There are unknowns, and when I am in trouble I say, “God, please help me.”

Do you consider your life to be a mission?

People say, “Why are you doing this? And at your age!” Success is very hard to define. Certainly it is not money or fame, not for me, but it is a certain value, and this value is definable by only you, because it is a variable quantity. My advice is to first find out what is your passion or your value, and then spend the rest of your life achieving that, and then you are happy. Doing this work is exactly what I want to do, and the greatest value for me is as a heart surgeon.

What does the future hold?

I believe Chain of Hope is a concept and that its time has come to be adopted globally. Its duty is to act as a spark for other people to produce a movement into the world.

Do you hope that your legacy will be that many more people will be well taken care of?

(Nods Emphatically) Yes.

You are an optimist?

I am an eternal optimist.

Do you think the world will become excellent?

One day, somehow.

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Chain of Hope.org

London, November 2016.

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