The Healthcare System for Hajj - Research Paper Example

The Healthcare System For Hajj Introduction The Hajj is an Islamic religious ceremony and is one of the most popular religious ceremonies in the world. It is celebrated during the last month of the Islamic Calendar (Dhu al-Hijjah) between 8th and 12th. Loosely translated, Hajj means an intention to make a journey. It involves paying homage to the holy city of Mecca and related holy sites to perform certain specific rituals.1 The annual pilgrimage is one of the pillars of Islamic faith alongside prayers, alms, fasting and profession of Islamic faith. A healthy person who has the means and ability to make this pilgrimage journey is expected to do so at least once in their lifetime.2 On arrival at Mecca, each pilgrim, makes seven circumambulations (Tawaf) around the Kaaba (the building was built by Abraham ). He then leaves for the Plain of Arafat, a few miles east of Mecca, where the Hajj culminates in the "Day of Standing". The pilgrim makes overnight stops in Mina en route to Arafat, and in Muzdaliffah on return (figure 1). On returning to Mina, the pilgrim stops at Jamarat to stone the pillars that are effigies of Satan. The new Hajjee (a pilgrim who has completed the Hajj) then makes an animal sacrifice (usually by proxy) as thanks for an accepted Hajj. After a farewell Tawaf, the pilgrim leaves Mecca.3 Arguably, Hajj is the largest human congregation on the face of the earth, Saudi Arabia receives millions of visitors from all over the world attending the Hajj festival every year. In a single year, the Kingdom of Saudi Arabia receives an average of 10 million international visitors who flock in to attend Hajj and other Islamic ceremonies such as Umra.4 The mass gatherings pose health risks to the pilgrims and the indigenous people because it attracts people from all over the world with different ailments. The congested environment increases the prevalence of transmission of infectious diseases such as polio, tuberculosis, malaria, hepatitis, cholera, dysentery and many others. If these risks are not addressed, the healthcare sector would be strained by epidemic outbreaks. Such was the case for many centuries, but the experience in hosting the Hajj pilgrims for centuries has enabled the Saudi Arabian government to put structures and measures in place to prevent outbreak of diseases that would strain the healthcare system. As such, Saudi Arabia is one of the leading lights in demonstrating how countries can effectively handle mass gatherings. This paper explicates some of the problems that Saudi Arabia’s healthcare sector faces and details how it has overcome these problems. After doing so, the paper contrasts these approaches to the ones taken by India, another country that experiences mass gatherings due to religious ceremonies. Through this juxtaposition, the paper intends to show the best practices in effective handling of mass gatherings to reduce the strain on the healthcare systems. Hajj and Saudi Healthcare Strain With this convergence comes the risk of importation of various communicable diseases from all over the world. Since it is a religious ceremony, the Saudi government does not impose bans on anyone who intends to attend. However, the government does not let this freedom to be its undoing by bringing all sorts of diseases into the country. The proximity between pilgrims facilitates easier and faster spreading of communicable diseases.5 These outbreaks of diseases can put a huge strain on the limited bed spaces and medications available in a country. The best way to address this looming crisis is to take a proactive approach. In healthcare matters, this involves taking preventive measures as opposed to reactive curative measures. Many of these communicable diseases are preventable and so the preventive measures should go a long way towards mitigating the adverse health impacts that such mass gatherings could bring.6 There are many diseases that can break during Hajj. Hajj has not been devoid of these disease outbreaks. The first outbreak occurred in 632 AD.It was a Malaria outbreak.7 At the time, it was being referred to as Yethrib fever. During the time, more than 1000 pilgrims were infected by the outbreak.8 Since then, disease outbreaks are common from time to time especially bacterial and viral infections. Over the years, the number of people attending the pilgrimage have kept on increasing thus increasing the proximity and accommodation pressures. In 2013, nearly 2 million international visitors arrived in Saudi Arabia for Hajj ceremony alone.9This annual hosting has prepared Saudi’s Ministry of Health to better deal with health risks during Hajj so that its healthcare system is not overwhelmed through diseases outbreaks. These measures include carrying out public awareness campaigns, instituting a surveillance system backed up by an infectious disease alert and response system. The measures also include planning in advance on how to tackle the various diseases ranging from gastrointestinal to vector-borne. The following are some of the measures that the Saudi government through its Ministry of Health in collaboration with other public health organizations such as the WHO take to reduce health risks and potential straining of Saudi’s healthcare system. Hajj Preparations Through experience, the Saudi government has learned the value of advanced planning for the Hajj ceremonies. These preparations provide unique opportunities to integrate preventive measures before the pilgrims start arriving. First, the Saudi government liaises with the relevant ministries in the various countries from where pilgrims come.10 For instance, in 2013 there were 184 nationalities attending the religious festivals. The Saudi government enlisted help from all these governments for disease control purposes. The Saudi Ministry of Health, for instance, offers vaccination instructions and special immunization requirements to foreign countries. In these instructions, the Ministry specifies which certificates of vaccinations an individual needs to have to be admitted into the country on arrival at the port of entry.11 This proactive measure is taken to avoid any confrontations during entry. For instance, those people from dengue-plagued countries or from the meningitis belt in Africa are expected to be vaccinated and immunized against their respective diseases to reduce carriers that facilitate outbreaks during Hajj. These instructions are then sent to the foreign countries’ ministries of health or their equivalents, the Muslim councils, travel agencies, airports and aircraft companies. Internally, the government undertakes public health education program throughout the country and especially in Mecca and Medina. The citizens are taught how to minimize respiratory and gastrointestinal infections during Hajj. As part of the preparations, the government ensures that there is adequate supply of clean water and food. It also procures and ensures that there is adequate supply of immunizations and treatment doses for any person that will require to be immunized before being let into the country.12 Advanced Planning To minimize the risks of outbreaks the Saudi government undertakes advanced planning activities. This planning starts immediately one Hajj concludes. The relevant authorities collect data from the concluded Hajj and analyze it. This enables identification of the patterns and prevalence issues that pose potential outbreak problems. The advanced planning has, over time, enabled the Ministry of Health to identify the areas plagued by the various diseases for example malaria, meningitis, tuberculosis and many other diseases. The identification of the regions and countries where such diseases are prevalent informs the preparation of specific instructions for pilgrims from those areas.13 Regular updates are, therefore, made to the public health programs and health regulations annually based on the monitoring and evaluation of the communicable diseases. Also, from this data, a more comprehensive alert and response system is put in place ready for the next Hajj. If need be, quarantine preparations are made for the different diseases that show the highest possibility of outbreaks. Therefore, the Saudi government does not take a rest, it is working constantly to prepare for the upcoming Hajj festival, after which it starts to prepare for the next. Surveillance, Alert and Response All the aforementioned measures are taken before the pilgrims arrive at the points of entry. Now, during Hajj the Ministry of Health uses its IT and surveillance systems to monitor the pilgrims and detect any outbreaks through its alert systems before initiating the relevant responses.14 The Saudi government has one of the highly sophisticated and advanced health surveillance systems which it uses to monitor diseases during Hajj. During Hajj, 25 hospitals are dedicated towards handling any health issues from the pilgrims. The pilgrims, regardless of their nationalities, are entitled to receive free treatment from these hospitals. In total, the hospitals have an average of 5000 hospital beds where a minimum of 500 are dedicated to patients with severe illnesses.15 All infectious diseases that could rapidly spread in mass gatherings are constantly monitored during the ceremony. These include diseases such as malaria, polio, yellow fever, tuberculosis, SARS, MERS- CoV and respiratory tract infections. All the health facilities are connected to a single database managed by the Saudi Command and Control Center based at Mecca.16 The hospitals are supplied with some of the latest advanced medical and communication equipment to facilitate easier and faster communication. The hospitals are then given the necessary threshold instructions. The officers in charge are notified on the disease cases they need to report instantly. The advanced systems collects the data keyed in the specific remote hospitals and then integrates these bits of data to form meaningful analyzed information that the Command and Control Center can use for decision making purposes. The data is collated and displayed on a giant screen wall. At any point during the Hajj ceremonies there are more than 100 analysts who are analyzing the data displayed on the giant wall which also acts as an interactive board with the hospitals and other health facilities in contact with the pilgrims. If an outbreak is detected, an alert is sounded and a response system is put in place. The pilgrims in the affected areas and camps are advised on the precautionary measures they should take to mitigate the spread of that disease.17 The advanced IT system is also applied beyond the Command and Control Centre. For instance, all the ambulances are fitted with sophisticated diagnostic machines which are connected through a local area network to the hospitals and other healthcare facilities.18 As such, after responding to the distress call, the nurses in the ambulance relay information in advance about the primary medical procedures they have performed on a patient and any other relevant information about the patient to the emergency unit of the hospital they intend to take the patient. The doctors at the hospital, therefore, have sufficient information to act upon even before the patient arrives. This allows for faster decision making and consequent saving of lives.19 For response purposes, the Saudi government has a group of experts drawn from different disciplines ready to diagnose and recommend the necessary response to a problem. The government also enlists help from the WHO and the Centres for Disease Control and Prevention Centres or their equivalence from the US, UK and France.20 Outbreaks Prevention As mentioned earlier, there have been many disease outbreaks during Hajj. Every outbreak has been used by the Saudi government as a learning opportunity. Vaccination is the major preventive means of securing the indigenous and the international visitors.Every person who hails from an area prevalent with a certain disease has to present a valid certificate showing that they have been vaccinated against the same. For instance, people from Africa and South America have to be vaccinated against yellow fever. If one has not been vaccinated then they will have to be vaccinated then monitored for a few days before being let to interact with other people.21 All people below the age of 15 who hail from polio-prone areas are vaccinated against polio on arrival whether or not they have been vaccinated against the same before.22 At the height of MERS-CoV scare, the government advises all people below the age of 12 and older people over the age of 65 to abstain from attending Hajj.23 This advice also applies to people who are terminally ill or have autoimmune conditions. Therefore throughout the years, the measures being taken have been more and more comprehensive. The following are some of the examples of the main problems posed and how the Ministry of Health has dealt with them. Vector-borne infections The main vector-borne disease during hajj is malaria. As noted above, it was also the first disease outbreak in the history of Hajj, as far back as 632 AD. In 2011, 19 cases of malaria were recorded among the pilgrims. The number rose to 48 in the following year.24 Most of the people who contracted malaria during Hajj entered into Saudi Arabia as carriers of malarial pathogens. The pilgrimage conditions exacerbated the intensity of these pathogens activities hence making the person sick. To avert the risk, the Ministry of Health undertakes an insecticide spraying campaign in the areas where they pilgrims will be hosted.25 This spraying campaign is carried out throughout the year as a precautionary measure; however, just before Hajj it is intensified. The program coordinators are tasked with identifying the housing units that will host pilgrims, especially those from areas plagued with dengue and malaria and then spraying these houses in advance. The program goes a step further to spray even Mt. Arafat and Mina where the pilgrims visit during their pilgrimage. Gastrointestinal Infections Gastrointestinal infections are a major challenge and pose a huge health risk rivaled by respiratory infections only.26 These infections the major cause of hospital admissions. This is because, even though the government has undertaken to secure the water and food being used, the individual’s food cooking and storage environment may be compromised. The main reason for gastrointestinal infection has been identified as use of polluted water and preparation of food in non-healthy environments. Poor personal hygiene and poor food storage mechanisms are also to blame for these diseases.27 The Saudi government takes measures to reduce the prevalence of gastrointestinal outbreaks through taking various protective measures. For instance, the Ministry has a task force in place to inspect and test the quality of the water being used during Hajj every day.28 When there is suspected outbreak, the water supply is inspected after every few hours to avoid an outbreak. The chlorine in the water supply is also changed daily and the dispensing equipment checked whether it is functioning correctly because any malfunctioning could be disastrous. To further safeguard against gastrointestinal infections, the Ministry of Health has a team of inspectors in all the hotels and hospitals that host pilgrims. These teams inspect the health conditions of the kitchens and the kitchen staff. The staffs are tested whether they are carriers of gut pathogens. Mouth swabs nail components of the kitchen staff in hospitals and hotels are taken for testing. The food is also tested to ensure that it is healthy for consumption. Furthermore, the ministry bans pilgrims from coming into Saudi Arabia with fresh food. All the food consumed and being cooked should be from Saudi Arabia, having undergone the rigorous inspection and tests from the relevant authorities.29 Currently, diarrhea, dysentery and cholera are the main gastrointestinal diseases that plague the Hajj celebrations. The Command and Control Center has a special surveillance on these diseases. Once these cases are detected the Control Center move with speed to quarantine the affected patients. The disease analysis and spreading pattern then enables the identification of the source of the disease which is then addressed. Respiratory Tract Infections Airborne diseases are another category of diseases whose prevalence is heightened during Hajj. The congested environment and the humid air exacerbate the situation.30 The most common conditions here include tuberculosis, Pandemic Influenza H1N1, SARS (Severe Acute Respiratory Syndrome), influenza, pneumonia and MERS (Middle East Respiratory Syndrome). Since controlling respiratory tract infections may be problematic, more precautionary measures are taken. To date, there are no major outbreaks of respiratory tract infections although there have been a few scares every now and then. MERS-CoV cases are closely monitored by the Control Centre and reported to the WHO for immediate response. Only 100 cases of pneumonia have been reported so far, after which the government has taken a proactive approach through vaccination.31 Thirty four cases of H1N1 have been reported so far. The government has instituted intensive screening for H1N1 on pilgrims from regions where the virus is common. Whereas the Saudi government through the Ministry of Health has been able to manage most of respiratory tract infections, it is still struggling to contain tuberculosis and meningitis. These diseases are airborne and are spread through breathing contaminated air. The reason why tuberculosis has not been managed is because it has a very long incubation time. Therefore, even if one contracts TB during Hajj there is little data to show that one did contract since the pilgrims will have already travelled back home by the time the symptoms start to show. As for meningitis, it has many strains which make it hard to manage and vaccinate against. Meningitis has been straining the Saudi Arabian healthcare system since 1987 when there was an outbreak. During the 1987 outbreak, more than 640 cases of meningitis were reported.32 From that Hajj season, the Saudi government has made it compulsory for all pilgrims to be vaccinated before entering Saudi Arabia. Also to be vaccinated are those people living near the places where Hajj celebrations take place. The last preventive measure which is compulsory is the issuance of oral ciprofloxacin on entry.33 The strains of meningitis have made its containment a major challenge. Through constant monitoring, however, the strains are identified, studied and new immunization developed. The Ministry of health and that of Hajj are engaged in constant research aimed at identifying and sourcing the new and varied traces of meningitis through reverse engineering of the viruses. These are then used as immunization for the people coming from meningitis-prone areas around the globe. India’s Religious Festivals and the Healthcare System India is another country that experiences high levels of religious activities and ceremonies. As such, there are many mass gatherings which, in turn, pose health risks. Indians celebrate a host of religious festivals, but the major one are the Holi festival, Ganesh festival and MahaKumbhMela.34 Even though these festivals started centuries ago, the Indian government has not instituted measures to curb the spread of communicable diseases like the ones the Saudi government has put in place. The following are some of the illustrations that show how the Indian healthcare system has been strained due to inaction on the part of the government to take the necessary precautions. The Holi Festival The Holi Festival is an annual religious festival that celebrates the abundance of harvests and welcomes the spring season. This festival is celebrated all over India by the Hindu majority who form nearly 83% of the population.35 The festival is celebrated through smearing of paints and colors on one another. This main ritual has, however, been a major cause of health concerns since it has caused a lot of dermatological complications among the participants. Every year there are about 150,000 people who are diagnosed with skin cancers.36 A study conducted by Ghosh and others on these individuals showed that most of them have at one point in their lives participated in this popular ritual in India.37 These studies have identified the paints being used as the major cause of these skin complications. It is alleged that the people participating in this color-smearing ritual have neglected the color samples prepared from natural sources such as vegetables and flowers in favor of the industrial colors which are prepared through mixing of chemicals. These chemicals are responsible for the skin complications that plague the Indian people every year after the ceremony. Originally, the colors were prepared from the flowers since the festival is celebrated at the onset of spring.38 However, due to hard economic conditions the people prefer to use colors made of chemicals since they are cheaper than the natural colors synthesized from flowers. While causing skin cancer is the worst case scenario, these industrial colors also cause itching of the skin, blindness in some people, scaling of the skin and even excruciating pain. The industrial dyes also reinvigorate the intensity of acne and eczema and asthma. If only the government takes preventive measures then these diseases and conditions will not be witnessed in high levels as they are at the present. For instance, the government through the Ministry of Health and that of industrialization should make sure that the manufacturers of these industrial dyes produce and sell commodities that are safe for use.39 If there are side effects, the government should oblige the manufacturers to clearly stipulate so to enable the final user to make informed decisions when they choose to buy these products. The source of the dye, its various components and possible side effects should be explicated on its packaging material.40 Additionally, should increase its efforts towards sensitizing the public to shun the industrial dyes and use the natural ones instead just like the ancient people used to. It should also pass the necessary legislation on the use of harmful substance to make industrial dyes and subsidize the price of the natural dyes so that the citizens can acquire it more easily. Ganesh Festival The Ganesh festival is another popular Indian religious festival. Basically, Hindus people pray to their idols and then immerse them in large water bodies according to Hindu faith. The major public health problem with this festival is that it spreads skin infections and also kills fish and other aquatic animals.41 The idols being immerse are responsible for these negative health effects. Many of them are prepared from tins, Plaster of Paris (POP), and other toxic metals.42 Furthermore, for decoration purposes, they are painted using paints which contain components such as mercury, lead, and carbon which are detrimental to the ecosystem. Each year more than 160,000 idols would be immersed in the bodies of water such as rivers and lakes and left there.43 Apart from the fact that these rituals kill aquatic animals, they also facilitate consumption of heavy metals and other substances through the food chain. As a result, the rate of people suffering from liver and heart complications is increasing in India with studies pointing towards contamination of water and water animals such as fish as the main reasons. For instance, there was a research study that was conducted at Lake Hussainsagar prior to and after the festivals. This research established that the levels of metals such as arsenic, mercury and lead increased by more than 20% and so did the instances of patients complaining of the nervous system complications, kidney failures, heart complications and liver damage.44 The government is increasingly getting concerned with the number of admissions in the healthcare due to these religious festivals. It has put some measures to safeguard against the same but they are weak efforts. For instance, the government is undertaking community education projects to promote the use of clay idols like in the ancient times. However, since these festivals are heavily commercialized, very few people are willing to celebrate using “dull” idols that are not shiny and heavily decorated. The government has also dug around 48 ponds specifically for Ganesh festivals so that the water in large water bodies are not contaminated but very few people are making use of them.45 MahaKumbhMela Of all the India’s religious festivals, the MahaKumbhMela is the most popular and has the most attendees. This festival is arguably the largest human mass gathering as it brings together more than 80 million people from across the globe together at once.46 It is held after every 12 years and involves the pilgrims, indigenous and international, bathing in the waters at the confluence of river Ganges, Yamuna and mythical Saraswati. Despite this huge mass gathering, the ministry of health has not taken any special measures to safeguard against the spread of communicable disease. The Ministry of Health has built a camp by the river where the pilgrims stay during pilgrimage. It has also built 10 hospitals which are situated at strategic points within the camp and one at the centre of the camp with an ICU.47 Evidently, this is not enough. The Saudi government prepares for the Hajj by ensuring 25 hospitals are ready and dedicated towards handling health issues from the pilgrims yet it only envisages receiving a mere 2 million people. 10 hospitals to take care of the largest human gathering in the world is not sufficient. As a result of this health risk concern, a team from Harvard University Global Health Institute rolled out a pilot program that, if successful, would provide a blueprint for the Indian government and other healthcare stakeholders to use to safeguard the health of the pilgrims. The study used information technology to monitor outbreaks of diseases. These outbreaks had been a common occurrence throughout its history and at one point more than 500,000 people were affected by cholera before the situation was arrested.48 The Institute connected the hospitals through an internet hotspot. The problem with the previous managements is that they relied on the telephones and mobile phones which often failed communications since the network was jammed during the festivals.49 Through the internet, the Institute had better access to data, could detect outbreaks sooner and initiate response to arrest the situation. It recommended the use of Twitter and other social media platforms to monitor such large gatherings. It also recommended the use of telemedicine to the Indian government to manage disease outbreaks.50 Conclusion Comparing and contrasting between how the religious festivals are handled in India and Hajj in Saud Arabia show gaping differences. Despite all the religious ceremonies documented here being centuries old, India has still been reactive in its response unlike Saudi Arabia. To date, the Indian healthcare system still witness an increase in patients after every religious ceremony that brings together multitudes of people. However, Saudi Arabia has shown a great deal of learning through experience. The unfortunate occurrences of disease outbreaks have all been but a learning opportunity to the Saudi healthcare stakeholders.51 As such, through their proactive measures their healthcare system is experiencing less strain each passing year as more and more interventions are being designed. Countries all over the world have a lot to learn in handling mass gathering from the way the Saudi government and its Ministry of Health handles the Hajj pilgrims. References Erin Allday, Hindu holy event yields health insights. SF Gate (4th June, 2013), http://www.sfgate.com/health/article/Hindu-holy-event-yields-health-insights-4328006.php#page-2 Harunor Rashid et al, Viral respiratory infections at the Hajj: Comparison between UK and Saudi pilgrims. 14 Clinical Microbiology Infections 569 (2008). Nishika Patel, “Toxic” Indian festivals poison waterways, Reuters.com (18th August, 2008), http://www.reuters.com/article/2008/08/18/us-india-festival-pollution-idUKDEL3263220080818 Nita Kulkarni, Shocking pollution during the Ganesh festival, Nitawriter.com (26th September, 2007), http://nitawriter.wordpress.com/2007/09/26/shocking-pollution-during-the-ganesh-festival Qanta Ahmed et al, Health risks of the Hajj. 367 Lancet 1008 (2006). Redorbit.com, Hindu festivals bring pollution to India’s waterways. Red Orbit (4th June, 2014), http://www.redorbit.com/news/science/1524819/hindu_festivals_bring_pollution_to_indias_waterways/ Sudip Ghosh et al, The “Holi” dermatoses: Annual spate of skin diseases following the spring festival in India. 54 Indian Journal of Dermatology 240 (2009). TawfikGhabrah et al, Assessment of infection control knowledge, attitude and practice among healthcare workers during the Hajj period of Islamic year 1423 (2003), 39 Scandinavian Journal of Infectious Diseases 1018 (2007). World Health Organization, Health conditions for travelers to Saudi Arabia for the pilgrimage to Mecca (Hajj). 84 Weekly Epidemiological Record 477 (2009). World Health Organization, Health conditions for travelers to Saudi Arabia for the pilgrimage to Mecca (Hajj). 88 Weekly Epidemiological Record 343 (2013). ZiadMemish et al, Hajj: Infectious disease surveillance and control 5 (2014). Read More