Introduction

In an environment dominated by an emphasis on treatment to the exclusion of prevention, Dr. Zaazoue is inducing a cultural shift in attitudes toward health and healthcare. He is creating a first of a kind system to deliver preventative health education directly to Egyptian children and their parents in ways that allow them to take charge of their own health.

Mohamed is targeting all socio-economic segments of Egyptian society with an approach that is less about combating any one specific disease, and more about moving Egyptians from the role of passive consumer of medicine to that of active health seeker. First, he has set off to make learning about preventive medicine interesting and user-friendly, recognizing the current perception that it is a tough and boring process to become aware of allof the various diseases and all of their corresponding symptoms and preventive measures. A series of competitive quiz games held everywhere from hospital waiting rooms to makeshift tents in the desert and a newly created character featured in coloring books, puppet shows, and a soon-to-be television cartoon serieshelp achieve this. Mohamed targets children as a key leverage pointin this process recognizing that the prevailing passivity toward health has not yet been ingrained in them and that parents are much more likely to pay attention to information related to their children’s wellbeing than to their own.

Mohamed has simultaneously zoned in on the importance of having the medical profession also play its appropriate role in encouraging a culture of active health prevention or wellness. For this, he is going directly to the source and reorienting future doctors while they are still in medical school away from an approach centered on simply giving medication instructions to patients to one of health educator, partner and collaborator. Already having mobilized more than 400 medical school volunteers in almost every governorate in Egypt for his health awareness campaigns, Mohamed is aiming to introduce credited field work as part of the medical school curriculum to yield more empathetic doctors who can effectively relate to and communicate with their patients. Mohamed is also recruiting and mentoring other groups interested in specific health issues affecting the country, offering them a legal umbrella – his Healthy Egyptians CSO – with hopes of creating a broad coalition of local organizations focused on helping Egyptians lead proactively healthy lives.

While the government of Egypt is estimated to spend up to six percent of GDP on health and there are more physicians in Egypt per 100,000 citizens than in most developing countries, morbidity and mortality rates in the country are high and increasing. Up from an already alarming 46 percent in 2010, for example, Egypt’s child iron deficiency rate rose to 51 percent in 2011. Not only does iron deficiency anemia lead to impaired physical and cognitive development in children, as well as an increased risk of morbidity, it also reduces work productivity in adults and contributes to 20 percent of maternal deaths. Egypt is also among the top 15 countries accounting for three quarters of childhood pneumonia cases worldwide. Termed “the forgotten killer of children” by UNICEF, pneumonia is indeed the leading killer of children under the age of five in Egypt. According to the World Health Organization (WHO), proper nutrition and hygiene account for 50 percent of the solution when it comes to preventing pneumonia, while vaccination accounts for 47 percent (the remaining three percent is a permanent variable). Yet Egypt’s National Immunization Program has not been updated in over 15 years and does not include the pneumonia-fighting vaccines. Indeed, Egypt’s health focus has been primarily focused on treatment, largely ignoring the role of prevention. The few times that the government has brought health education to citizens have been during times of sudden outbreaks such as the swine and avian flu epidemics that swept through Egypt.

And while the supply of health education is low, so too is the demand. Underpinning this situation, Mohamed believes, is a general assumption that medical knowledge is complex and reserved for doctors. Mohamed connects this unspoken consensus to the fact thatanyone who is not a medical, dental, or pharmacy student never encounters a class on health education in their entire academic career —- not in middle or high school, not in university.These students grow up to become adults who do not think to seek health information and doctors who do not think to share their exclusive knowledge. It is not uncommon to find patients who only know the name of their disease and how to take their medication. They do not know what the disease does to their body, what the dangers associated with not following the treatment protocol are, what other treatment options exist, or how to prevent getting sick in the first place. This stark segmentation of health education in the schoolsis onlyfurther compounded by traditional notions of authority- especially amongst an older generation of Egyptians – which also affects the doctor-patient relationship. This passivity toward health education not only threatens to see the traditional diseases go unchecked, but alsoposes a challenge to tackling the increasing advent of lifestyle diseases in Egypt.

To rupture the divide between health education and ordinary citizens, Mohamed worked with students at the School of Fine Arts at the university in which he was a final year medical student to create a comic book about a boy, named Montasser, who follows an unhealthy lifestyleuntil he contracts pneumonia from the evil villains, Hemo and Nemo, (named after Hemophilus influenza and Streptococcus pneumonia, the two leading bacterial strains that cause pneumonia). Montasser, which means “champion” in Arabic,then sees a doctor who advises him on how to lead a healthy life – wash hands, do not eat anything that has fallen on the ground, cover your mouth when coughing and sneezing, etc.–and how to overcome the illness.With 8,000 copies of this comic book, which also serves as a coloring book, in hand, Mohamed started conducting awareness workshops in his university hospital’s waiting rooms. But rather than lecture, Mohamed and his team of volunteers,whom he recruited as a managerial board member of the Egyptian Medical School Students’ Association (EMSA), tell parents they are conducting a competition for which the children of all winners will get a prize. With the parents’ attention locked in and a general mood of playful interest established, Mohamed’s team conducts a short presentation on the preventative steps of pneumonia, including where they could purchase the vaccine, if interested, and hands out a one-pager that outlines the key points in very straightforward language. They then hand out the quiz and a few moments after, they partner with parents to give hints and review answers. All children end up receiving the comic books, the story of which the volunteers read to the children as the latter color in the images of the book with the accompanying crayons they receive as prize. Since starting in September 2011, Mohamed has continued to experiment with different interactive activities to incorporate into theses sessions. Theseinclude a puppet show that features Montasser, treasure hunts in which the hidden items are healthy food items, and role plays in which parents, children, and volunteers can act out the scenes of the comic book, as well as others they create.

Mohamed has teamed up with 20 local university hospitals in 15 governorates and volunteers from those medical schools to execute this ongoing health education. Medical students have been joined by students from other schools of the various universities, as well as members of the general public,who have heard about Mohamed’s initiative and want to participate. Mohamed provides the relevant training to these groups, including how to approach different scenarios they make encounter like an illiterate or hostile parent.

These teams have begun to expand outof hospital waiting rooms in health caravans to host health education sessions in the heart of various communities. Mohamed has also recently received permission from the Ministry of Education to host similar sessions in Egypt’s primary schools with the goal of identifying a champion within the school to train and lead the program during “parent days” as well as during ongoing sessions throughout the year. To round off public exposure to this health education, Mohamed is in the process of expanding the “Montasser Overcomes” comic book series to next focus on nutrition, with a special focus on iron deficiency anemia, as well as turning Montasser into a television cartoon series. Mohamed has already had significant success penetrating television, as well as newspapers, magazines and radio, during his campaign leading up to World Pneumonia Day. Indeed, Mohamed has produced a short documentary movie, which he makes sure is aired each time he does a television interview, about the current situation of pneumonia in Egypt and the state of public awareness in Egyptian families across the different socioeconomic classes.

Recognizing the importance of bringing many actors in to sustain the cultural shift he is trying to induce, Mohamed founded the Egyptian Coalition against Child Pneumonia, which brings togetherindividuals and CSOs in Egypt who have shown an interest in addressing child health, like the long-present Save the Children, and connects this groupwith the larger, Global Coalition Against Child Pneumonia to exchange resources and best practices. In one such example of collaboration, Mohamed produced an Arabic-language educational video about pneumonia, which the Global Coalition immediately sent to all of its members, who then posted the video on their homepages, giving the Egyptian Coalition immediate exposure. Mohamed has also gotten the leading professor of Pediatrics at his university hospital, Ain Shams University, to agree to endorse with his signature all materials Mohamed produces, recognizing that the “professor” title carries a lot of weight in Egyptian society. Mohamed is also leveraging the support of an enthusiastic professor (who immediately ordered 2,000 more packages – which include the comic book, coloring pencils, and the quiz – for his students after receiving initial set of 250), to begin the work of mainstreaming health education fieldwork into the medical school curriculum.

Mohamed was also able to bridge the business/social divide by getting a leading pharmaceutical company to donate enough vaccines to have 14,000 families vaccinated after a campaign Mohamed’s robust team of volunteers led. Recognizing that after learning about the preventative measures for pneumonia, some families will focus on the hygiene and nutrition, while others will want to also receive the vaccine, Mohamed knows it is important to find a way to make vaccines available at a reasonable cost. Currently, Egyptians can only buy the vaccine in pharmacies and at a price that is out of reach for a significant segment of the population. For this reason, Mohamed approached the Ministry of Health from the very beginning of starting his work. And after being told that one reason the Ministry has not moved forward on making the relevant vaccine available is the absence of local studies outlining the incidence of the disease — all currently available figures emanate from foreign organizations — Mohamed has organized a group of student volunteers to conduct the relevant study. More importantly, he is demonstrating that Egyptians will take preventative measures if the education is provided, and he is building a movement whose demand for such measures will be hard to ignore. Indeed, there have been signs of progress on this front as the Minister of Health, after quickly dismissing Mohamed from his office just a few months before, replied that he was looking to update Egypt’s National Immunization Policy and would start with the “Hemo” and “Nemo” vaccines when recently asked on a news program about Egypt’s health prevention measures.

Originally operating solely through a volunteer-based network coordinated through his position on EMSA, Mohamed is in the process of registering his own CSO. While planning to continue the volunteer and partnership nature that has characterized his work to-date, he is taking on a core team to serve as point people for the various initiatives. One such initiative includes recruited groups of people who may not have yet worked through all of the details, but are interested in addressing a health issue in Egypt through prevention and awareness. His CSO, named Healthy Egyptians, will offer them a legal umbrella, as well as opportunities to exchange ideas and problem solve with Mohamed’s team.

With a father and grandfather who are doctors, Mohamed always knew he would also put on the white coat. He remembers admiring his dad who would wake up in the middle of the night to answer a call to save a life. After sharing with his father, who had relocated the family to the UAE for work, that he would go to Egypt to pursue his medical degree, his dad advised him to move at the age of fifteen so he could in fact finish his high school in Egypt, and thus meet young people studying all subjects before entering the medical faculty in university.

He started going on rounds early in his medical studies and remembers observing many differences in the hospitals from what he was used to in the Emirates. While he was expecting the difference in tools and equipment, he was taken aback by the fact that there was no transfer of knowledge from doctor to patient. He started sitting down with the patients of his professors, explaining to them the ins and outs of the ailment they had. Rather than just dismiss a diabetes patient with a shot of insulin, for example, he explained what steps could be taken in the person’s daily life to prevent the next trip to the hospital.

An exchange program in the U.K. further reinforced that something had to change in Egypt as Mohamed remembers that the patients he saw those hospitals knew so much. They had researched ahead of time and come equipped with questions. This led him to search for an organization through which he could systematically address the issue that patients in Egypt simply did not know anything about their diseases – and were sometimes afraid to ask – and that doctors were trained to treat and not to communicate. He joined the newly established Egyptian Medical Students’ Association and was quickly elected to join the Board, from which position he began to recruit members of the Association to join his initial campaigns that would focus on the leading killers of children in order to propel a larger health education movement. Upon graduating university in February 2012, Mohamed has put his medical studies on hold to launch and lead Healthy Egyptians. Finishing in the top one percent of his class has allowed Mohamed, however, to be given the role of Resident at the University hospital, which allows him to have the title of “staff doctor.” This affirms his position as an insider to the medical establishment, without any responsibilities of practicing medicine.