The Hegazy Medical Center is one of a handful of clinics near Cairo involved in Khattab's pilot program that has been so successful in its results that UNFPA decided to continue supporting it in its new program for 2002-2006. The idea for the program was born in 1988, when Khattab attended a conference on maternal mortality. She wanted to understand why women in Egypt, as well as many other developing nations, were not aware of their gynecological health and effectively suffer in silence. For example, 56 percent of Egyptian women suffered from collapsed uterus, due to constant squatting, carrying and home deliveries. As a result, Khattab and colleagues undertook a community-based study where they knocked at hundreds of doors in a rural Egyptian area, asked women about their health and took them to a clinic to run some lab tests for them. What they found was a large percentage of women who did not go to clinics to examine their female morbidities due to social and economic reasons.

She approached women with the message: "It's our right to care about our bodies."

"Young women in particular, who feel powerless in the family hierarchy, have a tendency to downplay their own health problems," according to Khattab. Physicians, she said, were not aware of some of the morbidities women carry. This was due, in part, to a failure of physicians and health care workers who did not make an effort to understand women and their health problems. Khattab explained that the medical system lacked an emphasis on counseling and approaching womenís health in a holistic manner.

"We thought that physicians training is lacking somewhere and observed the problems of the organizational structure of the health centers," said Khattab. She added that physicians also take on a managerial task without any background and that nurses and technicians lack the adequate training. Khattab said she was one of the few people that believed that management is essential in running any health center. Physicians need to have an understanding of what management is so they can respond to everyday problems, according to Khattab.

Back at the Hegazy Medical Center, El-Fotoh proudly showed Earthtimes around the clinic. The walls there are bare except for the occasional posters featuring diagrams explaining common diseases and contraceptive usage. Despite the clinical look of the place, it is warm and friendly. Patients, who pay around $1 USD for their clinic visit, collected tickets at the door and waited patiently to be seen by a nurse or doctor. Many patients in the clinic during the Earthtimes visit were waiting for injections. But for those who came in for consultations, doctors and nurses took the time to talk to patients and explain to them how to use their medications and how to monitor their and their children's health. El-Fotoh said Khattab and her NGO, the Egyptian Society for Population Studies, have worked to change the behaviors of the centerís staff, making them emphasize their social interaction with patients in addition to their physical examinations.

Khattab said that it was not enough just to improve these health care facilities, but to make people use them. "If we make the place humanly acceptable, what else should we do?" she said rhetorically. "We can not work just improving health service providers, we must create a demand for services available."

Hegazy clinic certainly seemed in high demand. Its corridors were filled with patients walking in and out of offices. One young gynecologist, trained by Dr. Khattab, noted that more and more women have been coming to the center to obtain contraception and advice on the proper forms of contraception to use. Many of them, she said, were very knowledgeable about the different forms of contraception available to them and she has noticed in the past decade that more and more of her patients are only having between two to three children. Dr. Layla Assad Farad, a pediatrician at Hegazy, also received training from Khattab. She said that she was trained to promote the use of contraception after labor. She has been counseling both husband and wife on post-natal contraception, and according to her training, has instructed the husbands to use condoms while their wives use the loop method.

To maintain the sustainability of the project, Khattab decided to engage the support of Egypt's Ministry of Health and Population. She enlisted their support from day one and began to train them. "There was a period where we gave them the skills to take over everything," she explained. "We were training a nucleus of physicians, nurses and lab technicians so they could be the future trainers, and we succeeded in doing that. They now do the training themselves." Khattab and her team now monitor and evaluate the MOHP training.

The UNFPA's support of Khattab's program reflects their emphasis on non-traditional approaches towards population issues. Dr. Faysal Abdel Gadir Mohamed, the Sudanese director of the UNFPA field office in Cairo, said that in the past 10 to15 years, there has been a rapid increase in modernization, which has dramatically increased the means of communication available in rural area. "People have started to question things more--the Koran, their health," said Gadir. "People want to understand more, like a child being exposed to the outside world who naturally questions what he begins to see." This has led to a change in approach to population issues, he said. UNFPA is focusing its efforts on two main areas: reproductive health and population and development.

Egypt used to be classified as country A, but because of the improvements in past 12-15 years Egypt moved into B and C. As a result, the field office no longer handles direct support services or constructing health centers. Gadir explained that they now work in capacity development, advising health centers, and working with NGOs. Egypt has to deal with a major population challenge. With an estimated population of 65.1 million, fertility in Egypt had been on a decline starting in the mid-1980s. For the past 10 years it remained at a plateau, but Gadir noted that the trend is currently reversing slightly. Today, 37 percent of Egypt's population is under age 15 and growth is now projected in Egypt until 2025. By 2030, it is estimated that the population of Egypt will reach 120 million.

Lubna Baqi, Deputy Director of the UNFPA field office, said that their support of Khattab's project is essential to their program's mission, particularly in the area of young people. Almost 1/3 of Egypt is considered youth and marriage in Egypt is young (most people marry by the age of 20). In most cases, young couples conceive soon after marriage and know little about reproductive health. "We want to give them more information and provide an environment where people can seek counseling and advice," said Baqi. Baqi added that supporting Dr. Khattab's work is an innovative project for UNFPA. "We are trying to use the experience of that project and create awareness of why it is a useful approach and what application it has for the health sector," she added. It has already been successful in reforming the health sector on a small scale by improving the quality of health care, sensitive counseling, and understanding womenís broader health needs. These changes, according to Baqi, are difficult to make, and she has already been successful in accomplishing those goals. And unlike other UNFPA-supported projects, Khattab conducts her projects on a low budget.

Due to the success of the pilot program in Egypt, Khattab believes this success can be transferred to other countries. Women, who have benefited from the program, are the program's best advocates. The project, or the Giza study, started as a reproductive health-working group, with participants from Jordan, Syria, Sudan, and Lebanon. UNFPA sent an evaluating team to evaluate Dr. Khattab's program. Based on their evaluation, UNFPA said they would like to replicate it wherever they could. Khattab maintained that this program has universal application and isn't specialized just for the Middle East region. "Religion has nothing to do with it except it backs up the project," Khattab said. She said that religious backing from Islamic leaders gave her program more credibility. "I don't know why people think that Islamic societies have a different approach to health," Khattab said. "I was in many countries of the world--women are women no matter where they areóno matter what the religion. Why should we put those social barriers in doing anything?"

Khattab spent significant amounts of time working in India and a Navajo reservation in the United States. She said that the type of training she has designed is so flexible, that it changes according to the needs of the communities she works with.

What her work comes down to is basic human capacity building and proving her results by success. She recalled an incident in which a gynecologist, in the middle of a training session questioned why he needed to learn about the social components of health care. Three months later, in another session, he got up and apologized to Dr. Khattab, when he revealed that he began to see things through his mother's eyes. He told Khattab about his mother, who was subject to an operation years ago. Though the operation was a success, his mother told him that it was not the surgeon who saved her life, but another young physician who looked after her everyday, talked to her and counseled her. So far, Khattab has been successful in conveying the importance of the social sensitivity of medicine in a few sectors in Egypt. It is just a matter of time before she can spread this success elsewhere.