Every year over 2 million Muslims, from all over the globe, throng the Holy city of Makkah to perform Hajj. A similar number or more visit Makkah to perform Umrah during Holy the month of Ramadan, and at other times. Health of the pilgrims is of paramount importance to all of us. Prof M S Khuroo documents the health risks to pilgrims and reasons thereof during this life time journey.

Hajj is no ordinary journey and every believer wishes and prays for this trip for long hours in his life. However, there are several factors which put those on this life-time trip to major health hazards.
• Traffic-Related Problems: For most of the pilgrims especially from developing countries, Hajj is the first-time international travel trip and from many the only time to board a flight.  Second, quite a few of the pilgrims are not acquainted with the traffic rules, safe way to cross the roads and foot long distances to reach Haram on roads with speeding vehicles of 110 to 160 km per hour which can unnerve anybody. Thus, roadside injuries to pilgrims while crossing roads and reaching Haram is major health hazard to those from developing countries. Also, road traffic accidents with minor or major injuries on highways (especially Makah-Medinah highway) are unfortunate happenings.
• Age Factor: It is a common notion in our community that Hajj should be performed when one reaches ultimate maturity in age and many pilgrims are elderly with co-existing geriatric ailments and this trip puts additional stress to existing ailments. Physical stress, absence of family care-giver to elderly and changed dietary schedule can make control of otherwise stable chronic ailments in elderly like hypertension, Diabetes mellitus, osteoarthritis etc difficult and a potential health risk.  
• Phenomenal Gathering: A gathering of over 2 million in a limited area of few kms and all eager to catch the same time-bound religious obligation (manasik) especially Tawaf, Ramy, Jamarat, and travel between Makkah & Medinah in defined few days is no ordinary happening.  Thus, stampede with resultant injuries and casualties can occur at sites with focal heavy gathering (Tawaf or tunnels) or roads allowing incoming & outgoing pilgrims (Jamarat). Major fire to tents, flooding due heavy showers and hailstorms in Mina has been seen in the past.
• Harsh Weather Conditions: Saudi Arabia is a tropical region and it can be very hot especially when Hajj falls in summer. Temperatures can hit up to 50 degree Celsius.  Thus heat-related health problems namely heat exhaustion and heat strokes are common happenings. These illnesses more often affect pilgrims from temperate regions of the world and elderly pilgrims and those with other co-morbid illnesses.
• Infections: Infections are a major cause of morbidity and mortality among pilgrims. Respiratory infections (especially pneumonias) due droplet spread and GI upset including vomiting & diarrhoea due lowered personal hygiene top the list. These otherwise innocuous illnesses can be life threatening to elderly and those with comorbid illnesses. Middle East is a tropical region and pilgrims are prone to malaria especially chloroquine-resistant type and this should be kept in mind while advising those on this journey. Epidemic of meningococcal meningitis has been a big hazard during Hajj and controlled now with mandatory vaccination to pilgrims. Poliomyelitis risk can arise from pilgrims from regions with reported wild type infections. Yellow fever epidemic risk has been managed by mandatory vaccination to pilgrims from endemic areas. H1NI epidemic during Hajj is a new threat which has caught the attention of the health authorities and special health guidelines have been issued to control this menace. Vaccination now available shall possibly be a big step to control this infection during Hajj. Epidemics of cholera, typhoid, dysentery, hepatitis etc have been a story of the past due to meticulous safe portable water supplies, improved sanitation and enhanced socio-economic status of the country. 
• Stress Related Problems: Hajj is hard religious activity involving lots of spiritual concentration and physical effort. In addition self personal care like cleaning, washing, cooking, etc can put additional burden on elderly not accompanied by a dedicated care-giver. This stress can precipitate physical illnesses especially major cardiac events and strokes and many elderly pilgrims can develop depressive illness.
• Language:  Arabic is the official spoken language in Middle East and few people speak, communicate or understand other languages. Language barrier and non-availability of a translator can cause major problems in patients who visit for medical advice. Also language barrier can cause problems to pilgrims during cash transaction with taxi-drivers, restaurants, hotels or markets and simple instructions or orders in day-to-day activities like crossing roads, using lifts and elevators, performing Tawaf, calling for taxi etc.
Feedback at Khuroo@yahoo.com.
Table: Profile of Hajj Pilgrims as depicted from Inpatient Hospital Records
Pilgrim profile Percent Remarks
 Age above 65 years  54% Elderly pilgrims develop more often serious illnesses with  higher death rates
 Co-morbid diseases  55% Illnesses included COPD, hypertension and diabetes mellitus; all these contributed to higher morbidity and mortality
 Language barrier  63%  Such pilgrims had higher death rates
 Non-availability of translator   53.3% Such pilgrims had higher death rates
 Severe physical disability 16.7% Such pilgrims were severely disabled; could not ambulate more than half a kilometer and  had higher death rates
 Need assistance in Manasik 8.3% Such patients had higher death rates
Pilgrim Health Hazards
 Reasons for medical consults  Trauma; Pneumonia; Heart attacks; Heat exhaustion; Heat strokes; Diarrheas  Over half were referred to secondary or tertiary care centers as such patients could not be managed in primary care 
 Reasons for ICU admissions (serious illnesses) Heart attacks (60%); Pneumonia (26%); Diabetic complications (11.4%); Major Trauma (4.3%); Strokes (4.3%) Indians (18.6%) topped this list followed by Egyptians (15.7%) and Pakistanis (12.9%). Heat strokes contributed to this list when Hajj fell in summer season.
 Causes of deaths  Major trauma, Pneumonia, Heart attacks, Strokes;
Heat stroke  Deaths were more often seen in elderly,  in those with poor performance status and those with comorbid diseases
Source: Saudi Med J 2003; 24:1073 & 2006; 27:1373. Ann Saudi Med 2007; 27:101. Int J Epid 1983; 12:267. Lancet. 2006 367(9515):1008.

Lastupdate on : Thu, 8 Sep 2011 21:30:00 Makkah time
Lastupdate on : Thu, 8 Sep 2011 18:30:00 GMT
Lastupdate on : Fri, 9 Sep 2011 00:00:00 IST