Home is where the heart is | Albert Fenech

Inside St Luke’s cardiology department, nurses and doctors are enjoying a noisy party as their serene 55-year-old head waits for me inside his little modest office.

The unit is busier this time of the year, not because Christmas brings more heart problems in need of intervention, but because cardiologist Prof. Albert Fenech wants to send as many patients as possible back home to enjoy the end of the year with their families.

The joyful mood makes one quickly forget this is a hospital; a department where some of the most complicated surgeries are carried out, without anaesthetic, with the patients wide awake as Prof. Fenech and his team perform their life-saving interventions.

A BMW motorbike rider (Harleys are for posers, he tells me), the son of a Portuguese mother and a Gozitan father, Prof. Fenech has been heading the department since it was set up in 1995, after two decades in the UK where he established himself as a cardiologist and department head there.

“I left Malta in 1975 and I never thought I’d be coming back,” he says, reminiscing about the troubles of the time with the government and the ensuing doctors’ strike. At the time there used to be two cardiologists who were invited over to come and see patients in Malta, for two weeks a year each.

“Clearly that wasn’t enough,” he says, explaining his sense of guilt at seeing lots of Maltese with heart troubles having to travel to London with their families for treatment. “The government then changed and in 1988 I got a call to be one of the cardiologists to visit Malta. So I started coming over and it was quite obvious that things weren’t that good, because there were four of us who would come over – so for eight weeks of the year there was a resident interventional cardiologist on the island, and the rest of the time people had to get well enough to be able to fly to the UK, which of course wasn’t always possible.

“By 1992 I used to be ashamed that that should happen to an island like Malta. I guess it was easier in my case; I was established in London, but I couldn’t accept the fact… I used to see all the Maltese patients coming over with their families. OK the government would pay for the patient to come over, but the families had to pay their own way, and then spend a couple of weeks, if not longer. It wasn’t very nice to have to do that. I didn’t have a family so it made it easier.”

At the time, the British government was rationalising the health service.

“When a government uses the word ‘rationalising’ it means they’re going to fuck it up, basically,” Prof. Fenech says. “Their idea of rationalising the health service meant closing down a few hospitals by merging them.”

Relocating to Malta meant a drastic cut in salary for Prof. Fenech, but he says he has never looked back since. To give me an idea, he says that he is still not earning a quarter of what he used to earn as consultant in 1995 in London.

“The salary here is pitiful, at best,” he says. “But I guess there’s more to life than money, and in fact that’s why I get very angry when members of the profession make it sound as if all they’re interested in is money over here. Medicine is above that. I may be old-fashioned, I may be idealistic, but I put that into practice. I came over here and I’m proud that not one single patient has had to go abroad since we started.”

Still, the salary issue has to be sorted out now, according to Prof. Fenech, as European Union membership is leading to a veritable brain drain with many Maltese doctors wanted abroad. Just in the UK, a newly graduated houseman earns much more than a consultant in Malta.

“Not only is there a brain drain, but people would rather work privately outside than in hospital, because the government salary is so poor. I think the easiest way for government to do that is to separate the health service from the civil service. The health service shouldn’t have anything to do with the civil service, but at the moment they’re tied to civil service grades, which is pathetic.

“The medical profession as a whole is blackmailed, if you like. Because our first responsibility is for sick people, and the governments know that we do what we can for sick people irrespective of what they do. So they kind of take advantage of that. I’m talking of governments of any hue over the last 60 years, so it hasn’t been just one government. People can do a sterling work and we always come in the top six of health services in the world, so it’s something we should be proud of. You know they say, well, these guys can still make it sixth in the world with the paltry salary they get, why increase it? Because they know we will continue doing what we are doing.”

Despite this kind of ‘blackmail’, Prof. Fenech believes doctors should never go on strike to make their point.

“I don’t think doctors should ever strike, I think it cheapens the profession. That is the one sad aspect that I feel is still happening today, because no matter how people euphemise – strike action, a slow down or what have you – it’s not the government that is going to suffer, it’s the patients who will always suffer. It’s pathetic to hear a doctor saying that we don’t engage patients, we just inconvenience them – well I’m sorry that’s not right. When people are sick the last thing they need is an inconvenience. So I think there’s a strong case here for arbitration, compulsory arbitration. If you’ve got a case you get it reviewed by someone else and each side abides by the decision.”

Meanwhile the last weeks saw one of Prof. Fenech’s colleagues, cardiac surgeon Alex Manche, getting a staggering Lm20,000 cut in his salary following pressure from the Medical Association of Malta to level the pay packets of government consultants, even though he was exclusively bound not to work privately.

“Alex had a British passport. The problem is that yes, there was a big discrepancy between the salaries of some individuals and the local salaries, and that is obviously wrong. But the way we go about it isn’t by slamming the chap who’s getting the salary that you want, it’s by making sure that in a talented and classy way – and by classy I mean with a bit of decency – you encourage people to recognise that the salaries should be uplifted,” Prof. Fenech said. “I see eye to eye with MAM because I agree with arguing the case for better salaries. The mistake they made was personalising it, because then the sad thing is that you lose sight of your original claim which is fully justified. If you just stuck to the guns saying this is what we want, and not be led by the nose into bringing persons into it… The minute you do that you get the response that happened. Now what happened? The MAM lost quite a few points of reputation, because people immediately rallied around Alex who is a very loved and, quite rightly, a respected surgeon. They should never have done that.”

I tell Prof. Fenech there is public resentment against consultants at St Luke’s who engage in private practice while they keep long waiting lists at the public hospital – a claim which clearly angers the cardiologist who insists that such sweeping statements should be investigated and grounded in fact, even though the health minister himself has been blaming doctors for the waiting lists.

“I have to see that. I’m not aware of that happening, but I’m told that this kind of thing happens. If it does happen, it happens among a minority. I’ve heard about it but I’ve never experienced it myself. I haven’t come across consultants who do that. All I can talk about is my own field, in cardiac services, and we have a waiting list that is too long, from immediate to about a year and a half, depending on your case. I’m talking about investigation here. For treatment, like cardiac surgery, we’re talking about two weeks, so that’s pretty good. Most of the medics that I know are dedicated. They’re forced to do private practice because of the salaries, but I don’t know that people make waiting lists longer here just to boost private practice. I don’t know that and I’d love the people who make these allegations to come out and prove them. I know even the minister of health said that. Well, if I were the minister of health and knew that was happening, the first thing I would do is to take them up to the medical council. If that is happening it is obscene, just like I find it obscene when they give a whole reputation a bad name by overcharging people, because they are always a minority.”

Does he think it is feasible to keep health services free of charge?

“I’m a great believer in the national health service, so I think in theory I would love the National Health Service to remain. Unfortunately, the practicalities of it are different. When the NHS was invented in the late 40s, all you needed was a theatre room, some knives, a few beds and an x-ray machine and a few drugs. Nowadays medicine is one of the most technically advanced… do you know what the health service was like in 1972 in Malta? It was all based on means-testing – depending on your income category you paid so many of the total, and the total was subsidised. So we had that kind of health system here, and it was very fair. But of course we are in a stupid situation here now because elections are won with such a few people, all you need is 5,000 people. When they put 50c for drugs that would have cost you Lm25 to buy, it was made into a political thing. Oh yes we’ll take it off. And then? What are you left with? The health service should remain out of the political arena. It’s used as a football too many times.

“Because we’re used to it being completely free, there was an idea some time ago that people should put at the bottom of medical reports the cost of whatever the intervention cost. The pace makers we use today can cost up to Lm14,000. I don’t think people realise that. When something is free you don’t realise its value.”

At his unit, Prof. Fenech has a great track record to boast about.

“I can only talk about cardiac services because I know the statistics intimately. I mean we haven’t lost a patient during an angioplasty for a long time, and I like publicising that because part of the success of any procedure is people feeling confident about the system that’s going to treat them. If they’re putting their lives into someone’s hands, it’s good for them to know that these hands have done a good job. So the only time that I seek publicity is only to publicise that this is a good place, our results are as good and in many cases better than places elsewhere. We’re one of the few countries in the world that has a 24 hour heart attack service. Other countries have Monday to Friday 9am to 5pm, so if you’re lucky enough to have a heart attack Monday to Friday 9am to 5pm, fine, you’ll get treated. But unfortunately most of the heart attacks happen at night time. We’re a great unit and I want people to know that before coming here.

“We try our best to be as humane as possible. It doesn’t take much to smile at someone, it doesn’t take much to look him in the eye, and it certainly doesn’t take much to be polite. It gives me great pleasure when people tell me they like coming here, because it’s not like being in hospital, and the people aren’t stuffy or cold or Nazi-like towards them. Sometimes it’s the few giving a bad reputation to the good majority.”

I tell him Italy has witnessed a raging controversy over the right of a terminal patient, Piergiorgio Welby, who had muscular dystrophy, to terminate his treatment. Prof. Fenech believes patients have the right to stop treatment as it is ultimately a question of human dignity.

“If you see that someone has got an incurable condition that is causing a lot of distress and there is absolutely no future, and in some cases you know this is the situation, he can decide not to treat – which is different from stopping treatment. That is different, and it is acceptable. The problem arises when you have intelligent people who want to retain their dignity. Dignity after all is the one thing that makes us feel good about ourselves. I find it very undignified, for example, to be sick and have to be put in a bed in a f****** corridor. That to me is the most crass, undignified way of being ill. People can be undignified to you when you’re healthy, but when you’re ill, at least you should be able to retain your dignity.

“But to return to your question, if an intelligent person who knows what the odds are, knows what the future holds for him, I think he should have a say into the way the treatment goes. The only reservation people have about that is that it can be somehow abused. I think certain controls can be put on that, and there have been several cases where people have asked for their machines to be turned off. Life isn’t black and white, life is made of shades of grey, and where human dignity comes in I think there has to be a hell of a lot more understanding and open-mindedness about it. One of our prime oaths is to diminish suffering and retain dignity.”

Meanwhile the new Mater Dei Hospital is expected to open its doors this year – a much welcome development according to Prof. Fenech although it has to be accompanied by a change in mentality.

“It’s taken a long time (to complete) for lots of reasons, not least of which the Palaeolithic bureaucracy we have. It’s sad it’s been changed into a ping pong ball, sad they changed the plans at least three times that I know of, but I’m all for it. If I want to do my house I’m not going to put it up for a bloody tender or be taken to court for a bloody decision I’ve taken. But there you go, that’s the ridiculous part of democracy for you. It is a beautiful hospital, it is impressive and it is up to date. And I’ll be the first one to say we need a new hospital, because this one was built in 1939 with materials that at the time were thought to be top class. You don’t put marble in hospitals. Marble absorbs dirt and blood, and after a few years no matter how many times you clean it, it’s still going to look dirty, and this place looks shabby, and it wasn’t built for the purposes we use it today.

“You need a new hospital but you also need a new mindset. If people are used to certain practices over here that have been giving the place a bad name, then you have to make sure these practices are upgraded and changed for new ones. The biggest problem that we have is that we train our physicians and teach them what they should do, and then they get into a system that tells them what they could do, which isn’t always what they should do. So immediately there is this discrepancy between what a doctor feels he should deliver, and what administrators tell him he can deliver, and it’s that problem that has to be bridged. And the problem is you can’t put an accountant into a health service and expect him to run it like a business, because there’s more to a health service than a business. It has to be run on different rules and regulations, and that is the big mistake that happened so far – that they tried to run the health service like a firm. It doesn’t work. The UK tried to do that and they’re now changing the plans, going back to what they used to have.”

Prof. Fenech does not mince his words when I ask him about the health of the Maltese.

“It’s bad,” he says. “Again I can talk about the number one killer, which is heart disease, and we’re top of the league. There are quite a few reasons for that, not all of them of our own making. Malta has got the highest incidence of diabetes in the world, and diabetes sadly is a major contributor to heart disease. Although we’re a Mediterranean country for many years we did not benefit from the Mediterranean diet, because we were a British protectorate so we had the British diet and everyone knows it’s one of the worst diets in the world. But that’s changing. Cigarette smoking and stress – those are also killers. Stress is relatively new; having more than one job is stressful. Life in general is more stressful today. Definitely one thing that takes away stress is if you stop poking your nose into your neighbour’s business, and just being happy with what you’ve got. These things are so intimately related to health.

“Let me tell you an interesting story. There was a study on rabbits. I used to feel sorry for rabbits because my coat of arms has a rabbit. Anyway, they used to feed rabbits a diet full of cholesterol so they develop heart diseases, and then they’d have a control where they feed other rabbits nice things, like lettuce and healthy food. And what they expected was that the rabbits with a lousy diet would have terrible arterial diseases, whereas the others would be healthy. But when they came to studying them they found that the guys with a lousy diet had actually better arteries then the others who didn’t, and then they found out why. The guy who looked after the rabbits on the lousy diet used to pick them up and cuddle them and be nice to them, while the others didn’t, they were just left in the cage. And that was the first study that started making people realise, hey there’s maybe more to this stress thing, love thing, than we read about. And now we know it through scientific evidence that people who are in a loving relationship live longer and have fewer problems with their heart than people who aren’t. People who have pets live longer and have better health profiles than people who don’t. So all of these things that we used to take very for granted in the past are very important.”

I tell him it’s the season when one usually indulges in more food and drink. Prof. Fenech says alcohol in moderation is good for the body, but in excess it is terribly bad.

“Alcohol is a funny drug because in moderate amounts it’s good for the system, and then too much of it is very bad, but very, very bad. Binging is very bad. Moderation is good, alcohol itself isn’t bad for you as long as you regulate it.”

When it comes to the right amount of alcohol intake, it depends if you’re a man or a woman. “Females have got much smaller livers than men, so they cope with far less, but two glasses of wine a day for a man, and a glass of wine a day for a woman is good. We’re talking about units of alcohol, so half a pint of beer is a unit, and a tot is a unit – that’s an English tot because a Maltese tot would amount to seven units,” he says jokingly. “In Scotland they have a wonderful expression: When you drink too much you spend a lot of time speaking to God over the big white telephone, because you’d be vomiting into the toilet saying ‘oh God’.”

Ultimately, a one-off dinner is not going to make a lot of difference, he says, so one shouldn’t think too much about the New Year’s or Christmas indulgences as long as they remain a once a year event.

“The best New Year’s resolution anyone can make is to have a balanced lifestyle, and that includes avoiding or handling stress in a different way, and concentrate more on the love around us than on the hate, because that is unfortunately a nasty cascade that destroys you and the people around you.”