Introduction

Abla is creating a cadre of skilled child nutrition professionals to support mothers in the first two years of their child’s life, a critical age for cognitive and physical development, to reach optimal child nutrition in Egypt. Abla is introducing a new profession of Child Nutritional Counselors to provide valuable information and skills to mothers around the clock through new Nutrition Centers in hospitals and in homes.

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As a child in a refugee camp and as an adolescent in a refugee camp too, his only mean to express himself and his pain resulting from the inhuman treatment of the Israeli forces, was like thousands others who led the same life, demonstrations and throwing stones at the Israeli forces. Both acts entailed that he would skip school. This negatively affected his academic record along with thousands of his peers. Yet Abdelfattah realized this negative impact and was determined to complete his education along with performing his duty, as he perceived it to be. He always wished that there would be an alternative method to make his case and that of his country heard.  He strongly believes in the following statements:

 

“All those who work with culture, work against war” – in a correspondence between Freud and Einstein,

“If we want to make war against war, we have to start with children”- Mahatma Ghandi

 

After he received his BSC of Biology from BethlehemUniversity, he was offered a scholarship by the French Government to do his MSC and PHD in Biological and Medical Engineering at ParisNordUniversity in France. There, along with his academic studies he also pursued his passion for theatre and painting through training and practice. This was when he came up with the concept of non-violent cultural beautiful resistance realizing its therapeutic effect on him. Participating in numerous painting exhibitions, acting, and co-writing a number of plays, made him realize that cultural resistance is not only as important and as effective as other forms of resistance, but also has an advantage over any other form of resistance; it encourages creativity and promotes non-violence, peace and respect of the other.

 

When Abdelfattah returned to Palestine in 1994, children in Aida camps had only the streets to express themselves and to play. Many found it easiest to continue to express their rage throw throwing stones at Israeli soldiers who never hesitate to fire back to kill. The result was either death or a life long of disability.

 

Abdelfattah became more convinced of the fundamental need for creating a space for children to vent and to learn how to express themselves in a non-violent way. This is why he created Al-Rowwad Centre where he works to expand the imagination of children and stretch out their capacities and creativities in order to help them lead a healthy childhood and allow them to have a future.

 

Abdelfattah is the General Director of the centre and the Chairman of the board of administration, which consists of six other people. To earn a living, he works in a private pharmaceutical company as director of the microbiology lab. On daily basis, after working hours, he goes to Al-Rowwad centre where he pursues his real life purpose of creating an empowered generation of Palestinian children.  In August 2005, Abdelfattah quit his job when his employer company refused to give him a non-paid 6 months vacation to focus on his creative work with children.

 

Thus the Ashoka fellowship will not only  be a great opportunity for him due to the stipend which will provide him with the time and space to spread his idea but also will help promote the concept of non violent resistance in the region with the hope of reaching peace in all conflict areas.

 

Abed has been nominated to us more than a year ago by the current Field manager of “Save the children” in Jordan, Amy Mina. He comes also highly recommended by Samia Meherez a professor of literature at AUC.

 

Abdelfattah made his choice of “beautiful resistance” since he was a child as he never participated in any demonstrations or uprisings, instead he focused on his artistic hobbies as painting and theatre. As a teenager and a young man, Abdelfattah was never seduced into joining any of the different political groups, as he believed that any form of aggression, bias or intolerance would eventually harm his country, Palestine more than benefiting it. In addition, his dream was more peaceful environment for children to grow up, away from violence, accordingly he chose to promote peace and not violence.

 

Abdelfattah is a hardworking and dedicated social entrepreneur who has already launched his idea and is currently extending his outreach. His work is well reputable on the national, regional and international. In partnership with Ashoka, Abdelfattah’s idea can reach its optimal goal, which could pave the way for real peace in the Middle East.

By creating an institutionalized system to provide support and resources for new mothers, Abla is promoting optimal child nutrition practices for children in the first two years of life, countering common misconceptions that are perpetuated by unskilled or misinformed health professionals or the community.  Abla focuses on educating and changing the behavior of new mothers so that they adhere to proper and safe nutrition practices for their children.

 

After realizing that doctors and even nurses often do not have the time, capacity, or sometimes knowledge to advise new mothers, Ablaintroduced a new profession in to the Egyptian health system for licensed “Child Nutritional Counselors.” Coming primarily from outside of the medical profession, this newly crafted profession is changing the landscape of the healthcare system as the counselors dedicate themselves to serving new mothers in hospitals primary care clinics, community centers, and in the mothers’ homes. Child Nutritional Counselors focus on educating and changing the behavior of new mothers so that they adhere to proper and safe nutrition practices for their children. Their support fills in a noted gap of services when it comes to consulting with mothers on lactation practices and the introduction of healthy foods according to children’s age brackets.

 

Although Abla works with traditional healthcare actors—doctors and nurses—to ensure that they have the right information to pass on to mothers, key to her work is engaging with people who are closest to mothers, are trusted by them and have the power to influence their decisions such as other mothers, midwives, family members, and community actors.Though seemingly simple provisions, the impact of systemizing and institutionalizing support services and resources for new Egyptian mothers cannot be underestimated. By completing a training and certification, these nutritional counselors can provide real-time health and nutritional support to new mothers during their child’s first two years of life – the most critical years for cognitive and physical development. In doing so, Abla is strategically targeting the most crucial population to help reach optimal nutrition rates in Egypt.

 

Acknowledging the value of Abla’s work, the Egyptian Ministry of Health and Population has agreed to adopt and integrate this new certification in to the public healthcare system.  In addition, the government has pledged to support Abla’s plan to create Child Nutrition Centers within public hospitals, Primary Health Care center, and community centers. Her work has been widely recognized and is spreading throughout the country.

The first two years of a child’s life are crucial to cognitive and physical development, affecting both the child’s early and adult years. Improper nutrition in the first two years of a child’s life, part of which includes a lack of breastfeeding and early introduction of formula, can result in a number of short and long term negative effects in terms of psychological and physical diseases as well as neuro-development delay. In 2010, the millennium development goals (MDGs) confirmed that malnutrition is one of the main causes of death of children under five. Additional causes are low breastfeeding rates and infection due to poor prenatal care. While there have been successful efforts by the government, the United Nations, and CSOs to reduce child mortality rates under the age of five, there have been minimal efforts that focus specifically on improving child development and survival for children under the age of two.

 

Despite reduced mortality rates for children under five, children under the age of two in Egypt are not meeting growth indicators such as height, weight, hearing ability, motor development and other benchmarks that need to be reached by a certain age, which is in part due to malnutrition. Mothers are not receiving adequate information regarding child health and nutrition from doctors, practitioners and health workers. Further, there is a lack of training on nutrition for health professionals, community workers, and doctors. As a result of poor nutrition, children under two continue to suffer from a variety of ailments including stunted growth (underweight and under height benchmarks according to age) iron deficiency, malnourishment, low immunity (breastfeeding increases immunity), and increased mortality rates. A lack of proper nutrition during the first two years of life has also been found to increase the incidence of childhood allergies, obesity, diabetes, and infections (mainly pneumonia and gastroenteritis). Not only does poor child nutrition affect early life, it also has negative long term effects such as an increased incidence of adulthood medical problems like hypertension, obesity and coronary heart diseases. Further, individuals and families suffer from high medical expenses and communities have to spend excess costs in health resources as a direct result of poor nutrition during early childhood. Currently, more than 50% of Egyptian children have stunted physical and cognitive development, making optimal child nutrition under two a national priority.

 

The widespread, long-term health benefits of breastfeeding are well-documented.  Despite this,only 28% of Egyptian babies are exclusively breast fed during the first six months (Egypt, DHS 2008) and 58% of Egyptian mothers were found to stop breastfeeding because of wrong beliefs of insufficient milk, lack of information on the benefits of breastfeeding, and lack of help from nurses on lactation management (unpublished research by Abla et al 2012). The lack of breastfeeding and increased use of formula was found to be responsible for 22% of neonatal deaths. Further, 81% of mothers reported that they do not get enough help with breastfeeding after the birth of their child and 71% of mothers who went for a follow up visit reported a general need for proper education on child nutrition. There are currently only 250 lactation consultants in all of Egypt and little to no resources regarding what and how to feed the child during the first two years of life—especially after the mother stops breastfeeding. Thus, mothers have very few resources and help available in regards to breastfeeding and child nutrition.

 

Additionally, 90% of medical school graduates do not have the opportunity for hands-on training since further university medical schooling is granted only to those who are in the top of the class. Newly graduated pediatric doctors are eager to pursue continuing education and specialized training to work in sub-specialties like neo-natal care, which requires specific training on children between zero to six months as well as after care and specific child nutrition practices that are neededuntil the age of two to ensure the optimal survival of the baby, but don’t have the avenue since there is no outlet for training outside the public university system.

In order to institutionalize a system to widely improve nutrition during the first two years of the child’s life, Abla founded the Egyptian Members of Royal College of Pediatrics and Child Health (EMA-RCPCH), using a three-tiered approach to target community actors (citizen sector workers, mothers, and family members), health workers (nurses and midwives), and doctors. While working as a pediatrician and neonatologist, Abla realized that doctors and nurses are an important resource for new mothers but they often do not have the time or knowledge necessary to provide new mothers with adequate training on breastfeeding and child nutrition. There is very little help and support for a new mother regarding how to properly care for and feed her child after she leaves the hospital.

 

First, Abla is introducing a new profession in Egypt known as a “Certified Nutritional Counselor.” These counselors can work in hospitals, community centers, as well as in the homes of new mothers to give child nutrition counseling—specifically from the time the child is born until the child is two years old—to new mothers. Abla has first designed a training and curriculum that is focused on nutrition during the child’s first six months, six months to one year, and one to two years. Each of these stages is critical in a child’s development. In addition to being properly trained on breastfeeding techniques, the nutritional counselors learn what types of foods should be introduced to the baby’s diet during these three stages. The nutritional counselors learn how to measure a child’s nutritional health as well as recognize and solve nutritional problems. Also integrated in the training are proper immunization practices so that the counselors can provide this advice to new mothers as well. Additionally, through Abla’s program, the counselors learn important communication and active listening skills. Integral to Abla’s approach is for counselors to urge mothers to bring someone with them -their husband, mother, sister, or neighbor- when they are meeting with the counselor or visiting a nutrition center so that the right information is reinforced in the close circle who are in contact with the mother and child. This way, the mother will not receive contradictory advice and more people in the community can become educated on optimal child nutrition practices. Outside of the major cities in Egypt, close knit communities and a strong emphasis on family makes extended family members and community members quite influential when it comes to child nutrition practices. Abla encourages mothers nurses and those who participate in the training workshops to spread the knowledge in their circle of friends and family, knowing the importance of word of mouth in Egyptian society.

 

A key element to the certification program is that anyone can complete the training and take the two tests (practical ad written) upon completion. The first audience that Abla is targeting to receive the certification is local community workers—CSOs,mothers, and family members who do not necessarily have a background in the health sector. Abla recognizes that mothers who have breastfed in the past are going to have much more of an influence in teaching and advising new mothers how to breastfeed and what foods to feed their infant than a male doctor would. Knowing the importance of breastfeeding and how little it is practiced in Egypt, many mothers have already signed up for the certification solely because they want to help new mothers do what is best for their children. Abla also recognizes that it is important to work with other health workers, including midwives, nurses, and doctors to receive the certification. Doing so will provide a larger network of support for new mothers as they learn not only how to breastfeed but also safe nutritional practices for babies through age two. Abla has succeeded at sealing initial negotiations with the Ministry of Health and Population, who have shown eagerness and interest to implement this certification nationally. More so, Abla’s curriculum for the certification has been finalized and informed with local insights relevant to the Egyptian context.

 

To ensure the sustainability of the certification program and the ongoing quality of the counselors, Abla has inserted a requirement for all of the nutritional counselors to become re-certified every two years. During the re-certification process, all nutritional counselors share extensive information regarding the number of cases they worked on, individuals they helped, and the type of support they rendered. They are also required to re-take the written exam so as to reinforce the knowledge learned during the training. Not only is the re-certification an effort to make her work sustainable, but it also provides her with an opportunity to collect data, monitor quality, and track impact. Also included in Abla’s impact measurement is the monitoring of newly certified counselors and practitioners by assessing child nutrition indicators amongst the children of the mothers who have received the counseling in comparison with national surveys in areas where the program is not being implemented yet.

 

Second, Abla is creating “Nutritional Counseling Centers” within hospitals to cater to mothers and offer them specialized guidance. Abla has already started two Child Nutrition Centers in Benha Children Hospital and Mansoura Medical Centre in Egypt. She is promoting the concept of these centers with the Ministry of Health, private hospitals, government hospitals, Primary Health Care centers (PHC), and other community centers. Additionally, Abla has also created family support groups in Qalyobia and Dakahlia governorates (states of Egypt) and is promoting this idea with other local health CSOs working in different governorates. Abla is securing partnerships so that hospitals will direct mothers to the nutritional centers if they need support or advice after they are discharged from the hospital. These centers can also provide immunizations and birth certificates for children. Abla has plans to significantly expand the reach and number of the nutritional counseling centers in the coming years.

 

Third, in addition to the certification that is opening a new profession to many without a health background, Abla has created a curriculum and training manuals for current and new doctors, nurses, midwives, and health professionals. This curriculum is focused on practical training through a community-centered approach to pediatrics, paying close attention to child nutrition under the age of two as well as child development indicators. Alba succeeded in having the Ministry of Health and Population adopt her program and they are currently committed to carrying it out in the Ministry of Health hospitals. Abla is continuously creating new training methods and opportunities in order to make it accessible and appealing. For example, she uses many visuals and compresses information into a shorter amount of time so that more people can attend. Abla transformed a twenty-hour training for practitioners on child nutrition (breastfeeding) that was developed by UNICEF and the WHO into a two-day interactive training. Abla noticed that people were not willing to dedicate this much time to the course and were not getting enough practical application of the material learned. So, she created a study at home module of the written information making it easier for people to study the materials at their convenience. Then, after finishing the written part, the trainee attends two days of interactive sessions using videos and practical application.

 

To scale and expand her work, Abla has created many key partnerships. In 2005, Abla became certified as an international lactation consultant and was elected to serve as the Secretary General for the Egyptian Lactation Consultants Association. She uses the current 250 lactation specialists from this organization to help with the training and monitoring of her program. Abla and her team of consultants conduct bimonthly follow up visits to monitor the implementation of the child nutrition standards that are taught in the training with the health workers in the hospitals. Another partnership includes Save the Children. By partnering with this organization, Abla has been able to extend the reach of her program to practitioners in public hospitals and clinics in Qalyobia (Qanater, Khairia, and Kafr Shokr), Zakazik, Qena, Bany Suif, Sohag and Assyuit.

 

Abla has also managed to get the Royal College of Pediatric and Child Health (RCPCH) to hold membership exams in Egypt. Having the test available in Egypt gives doctors the opportunity of continuing education with an emphasis on community based neonatal pediatrics. Moreover, Abla made Egypt the first country in the region to gain approval from the Royal College in the UK to hold the International Diploma of Child Health. Abla re-designed and adapted the course to fit the Egyptian context with an online module and assessment system. This diploma offers practical “bedside” training that is needed and will be a 6-month program. In June 2013, the Royal College approved the international accreditation of the Egyptian Pediatric Fellowship (EPF), which Abla and her team have been working on upgrading for the last few years. It is important to note that doctors have to pay a small for taking the exam or participating in the Fellowship. This revenue feeds back into her organization. Abla also relies on partnerships and grants for financial support.

 

 

Abla’s CSO, which relies heavily on volunteer consultants and employs only two other staff for administration and IT, is currently working in six governorates (states) throughout Egypt. By handing over her program to other CSOs and to the government, Abla is spreading her reach throughout the country.

Abla grew up as the favorite of her father and as a result was given family responsibilities and included in family decision making early early on in her childhood. During her adolescent years, Abla was involved in her community and from 1967 to 1969 she supported families who experienced loss during a recent war by collecting money and clothes and distributing them to needy families.

 

From a young age, Abla knew that her passion was working with children. She decided to go to medical school and study pediatrics so that she could work particularly with infants. Each hospital that Abla worked at she followed a personal mandate by asking herself how she could help improve the hospital, help her colleagues become better doctors, and how she could learn to serve her patients more effectively. In addition to a practicing pediatrician, Abla has been an educator, an innovator, a child health development professional, and a reformer wherever she has chosen to work.

 

After marriage, Abla and her husband moved to Kuwait for work. While working there, Abla implemented new initiatives in the hospitals that she worked at. She particularly focused on working with new mothers and teaching them how to breastfeed. In one hospital alone, Abla was able to raise the breast feeding rate from 10% to 90% in just one year. After working in Kuwait for 18 years, Abla decided to move back to Egypt so that her son could also attend medical school. Upon her return, she was shocked at the meager standard of pediatric care and the lack of community pediatric services in Egypt. Additionally, Abla was surprised at the large number of young medical graduates that wanted more on-the-job training but were not able to find work. Abla began to train many young graduates and although her efforts were admired by many, she faced opposition from hospital officials who were more concerned with saving costs than improving the quality of healthcare for infants and their mothers. This experience motivated her to start her own organization, Egyptian Members of Royal College of Pediatrics and Child Health (EMA-RCPCH), in 2007. She partnered with international organizations and local community workers to carry out her aspirations for an improved pediatric child nutrition and child care system in Egypt.

 

Upon meeting one Egyptian doctor who had spent his family’s savings on trying to pass the Royal College Fellowship exams, Abla decided that Egyptian doctors should have access to this type of continuing education at a cost they could afford and with practical training suited to their context. She succeeded at bringing the first clinical exam to Egypt in 2008, after many negotiations with the Royal College of Pediatrics in the UK and with the Egyptians ministries.

 

Abla has worked relentlessly with new mothers and community members to improve child nutrition and development in Egypt. Realizing that so many mothers in Egypt were depriving their infants of proper nutrition due to a lack of knowledge and understanding regarding breastfeeding, Abla also became determined to promote breastfeeding and other important techniques for newborns, such as skin-to-skin contact.In 2005, Abla joined the Egyptian Lactation Consultants Association, a local CSO for certified lactation consultants. By joining them and being elected as the Secretary General and Coordinator of their Child Nutrition program, she is able to expand her reach with their support.