Hajj and Health

The health of the pilgrims is of paramount importance to all of us. This document shall define how we can achieve this to perform a safe Hajj.
The holy Grand Mosque in Makkah [Representational Image]
The holy Grand Mosque in Makkah [Representational Image] Twitter/ @hsharifain

Prof Mohammad Sultan Khuroo 

Haj 1444 (H)-2023 (CE) tentative period, will fall between 25 to 30 June corresponding to 8 to 13 Dhuʻl-Hijjah 1444 and the first batch of Hajis from J&K will start their 40 days Haj journey on 21 May 2023.

This year Saudi Arabia will host pre-pandemic numbers and guidelines for travel of the elderly (above 70 years), women above 45 years without their Mehram, and children (< 12 years) have been stipulated. Vaccination for all pilgrims has been defined and vaccination against COVID-19 with one of the approved vaccines completed one month prior to travel is mandatory.

Haj Committee India has issued guidelines for Haj 1444 (H)-2023 (C.E.). This year, the Haj quota for India is around 1.8 lacs and J&K numbers may touch 10,000. The health of the pilgrims is of paramount importance to all of us. This document shall define how we can achieve this to perform a safe Hajj.

Health Risks 

Over the years there have been substantial improvements in the process of performing the Haj including shortened time periods, safe and comfortable international air travel, improved accommodation in the two holy places, and excellent Governmental healthcare facilities.

Govt of Saudi Arabia has revolutionized the structure and functionality of the Haj, which has had a major impact on the comfort and safety of the Hajis. 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.

Yellow fever epidemic risk has been managed by mandatory vaccination to pilgrims from endemic areas.  The epidemic of meningococcal meningitis has been a big hazard during Hajj and is controlled now with mandatory vaccination for pilgrims. Also, accidents due to fire in tents in Mina, flooding due to heavy showers and hailstorms in Mina, and stampedes during Jamarat and other sites have been addressed effectively.

Despite all that has been done, Haj continues to pose health risks to incumbents. Phenomenon gatherings, harsh weather conditions, essential religious obligations [manasik] especially Tawaf & Ramy al-Jamarat (stoning Satan), and travel between Makkah & Madinah bring special health risks to the pilgrims. Hajis continue to face four broad types of health risks which include road traffic accidents, respiratory and other infections, heat-related health issues, and worsening of co-morbid health conditions in the elderly.

Road traffic accidents with minor or major injuries on highways are unfortunate happenings. Roadside Injuries to pilgrims who are not accustomed to special traffic rules and safe road crossing is another hazard. Stampedes with resultant injuries & casualties can occur at sites with focal heavy gathering (Tawaf or tun­nels) or roads allowing incoming & outgoing pilgrims (Jamarat). Heat exhaustion and heat stroke can affect elderly frail pilgrims and may be life-threatening.

Infections are a major cause of morbidity and mortality among pilgrims. Respiratory infections due to droplet spread and GI upset including vomiting & diarrhea due to lowered personal hygiene top the list. These otherwise innocuous illnesses can be life-threatening to those with comorbid illnesses. COVID-19 has been a constant threat to pilgrims.

Fortunately, Govt. of Saudi Arabia has been able to avoid COVID-19-related catastrophes due to the implementation of strict guidelines and mandatory vaccination of the Hajis.  The H1NI epidemic during Hajj is a new threat that 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 controlling this infection during Hajj. Physical stress, absence of family caregivers for the elderly, and changed dietary schedule can take control of otherwise stable chronic ailments in the elderly like hypertension, Diabetes mellitus, osteoarthritis, etc difficult and potential health risks.

Health Check-Up 

By law, every Hajj pilgrim undergoes a dedicated health check-up. This check-up should stratify health risks to the pilgrim himself and to others during Hajj. A large population of potential Hajj pilgrims falls into middle/elderly age groups, where co-morbid diseases are a common occurrence.

Amongst these, Hajj may predispose some to exceptionally high health risks and these need to be counseled accordingly. Those with unstable coronary heart disease like effort angina or recent heart attack, overt heart failure, heart enlargement with low ejec­tion fraction (on Echocardiogram), uncontrolled severe hypertension, and difficult heart rhythm abnormalities fall in this group.

Those with lung disease, who require con­tinuous oxygen, are/become severely de-saturated at rest or on effort (fall of partial pressure of arterial blood oxy­gen), and have severe obstructive or restrictive lung func­tion tests need to be discouraged from Hajj. The elderly with stroke and severe physical disability and those with severe disabling osteoarthritis knees cannot tolerate the physical challenge of Hajj.

Diabetics with uncontrolled blood glucose levels; those prone to keto-acidosis and those with severe target organ damage should take great caution. Elderly with cataracts and significant visual impairment must have cataract surgery prior to embarking on Hajj. Children below 12 years of age are more prone to adverse effects of dehydration and tolerate infections poorly and are discouraged from Hajj.

Pregnant mothers with advanced stages of parturition should also use caution and postpone Hajj for next year. People who carry communicable infectious diseases like tuberculosis etc are a risk to others and are not allowed to perform Hajj till the infection is controlled.

People with co-morbid diseases which are controlled by medication/lifestyle modifications need to be counseled on how Hajj can affect their disease status and need advice on additional monitoring, medication, and advice on situations wherein they need a local medical opinion.

Such pil­grims should carry a medical report along with adequate supplies of medications from their primary physician. Those pilgrims who are otherwise healthy also need a routine dedicated health check-up, determined by their age and sex. It is worthwhile that all pilgrims carry an identity card that gives their demographic information, health risks (especially diabetes), blood group, allergies, and contact number in case of emergency.

Health Drills 

Hajj may be the sole international journey for most pilgrims from developing countries including India. While so, they are exposed to demanding circumstances to fulfill religious obligations (manasik) and supported by an unfamiliar healthcare system that is stretched to the full. To face these challenges pilgrims, need a Hajj health drill and I believe it is being practiced in many countries.

Pilgrims should be shown and interpreted good quality videos of the actual journey they are envisaging. These should define check-in procedures for flights, use of toilets on flights and at many locations, traffic signals rules and road crossing, simple sanitary practices, hand washing, use of face masks, and practices of waste/ sewage disposal during Hajj.

Pilgrims must watch and simulate drills of essential religious obligations like Tawaf, Sai between Safa and Marwah, etc. Exercise programs like daily swift walks for 20 minutes should be encouraged for at least 6 weeks prior to travel. Self-monitoring of health indices should be encouraged.

The use and availability of a thermometer are helpful in monitoring body temperature. Patients with high blood pressure should know how to use an automatic blood pressure apparatus, carry one with them and use it on regular basis. Diabetics should be trained to use a glucometer to monitor blood glucose and counseled on its application.

Diabetics should be educated on the symptoms of hypoglycemia and carry Glucose (not cane sugar) supplies to ward off an impending attack. The elderly on multiple medications should be able to recognize the tablets and self-help for drug intake for several weeks prior to travel.

A chart listing drugs with their shape & color and time schedule should help such pilgrims. All pilgrims should carry supplies of on-the-counter available medications for common ailments.

This includes simple analgesics like paracetamol for pain and fever, safe anti­biotics tablets for respiratory infections, anti-emetic for vomiting, anti-spasmodic for a tummy ache, and anti-diar­rhoeal tablets for GI upset.

A prescription defining medication carried by the pilgrim is essential for scrutiny at the check-in points. All pilgrim groups should carry a first-aid kit and somebody from the group should be trained in its use for minor injuries.

The group leader or attending medical officer should be aware of all health units in Makkah, Mina, Arafat, and Madinah and have contact numbers of such units. It shall be advisable if all pilgrims carry a cell phone and are able to contact their group leader or Hajj physician if needed. Thus, adequate practice on the use of cell phones may be envisaged for such circumstances.

Health Practice Manual

Each pilgrim must understand and use broad guidelines to look after his health and health problems so that he can fulfill religious obligations (Manasik) with the least disturbance. Fatigue is a common occurrence and should be dealt with by adequate rest and sleep.

Heat-related issues namely heat exhaustion and life-threatening heat stroke can be avoided by adequate water intake and by avoiding direct exposure to the sun. If unavoidable, the use of lightweight and colored umbrellas is an alternative. Fever, catarrh, and cough are common and should be managed early on by analgesic tablets and on-the-counter antibiotics.

GI upset like tummy aches, vomiting, and diarrhea should be managed by corresponding tablets and by maintaining adequate fluid intake. Attending and use of local medical centers should be used judiciously as it may affect religious obligations (Manasik).

All patients suspected to have heat stroke (rising body temperature above 1020 F and conscious disturbances) need to attend such units as an emergency. Respiratory infection causing breathing disturbances, chest discomfort, and blood-tinged phlegm suggests pneumonic illness and needs a hospital visit.

Diarrhoeal illness causing fainting, low urine output, and low blood pressure needs a hospital visit for intravenous fluids. Febrile illness which does not settle in a few days and causes debility should receive medical attention.

Pilgrims with underlying co-morbid illnesses should receive medical attention early on as simple flu-like illness or GI upset may worsen their underlying condition. It is worthwhile to take Hajj doctors into confidence while attending medical centers.

Hajj & Women’s Health

If a woman begins menstruating during the Hajj, she may continue all manasik except tawaf. This she can perform after the last day of her pe­riod. Women should be prepared with special needs such as sanitary napkins and pain medication.

Some women take hormones in the form of oral contraceptives to control their cycle and prevent menstruation during the Hajj. This practice though effective is debatable.  

Hajj for pregnant women carries special health-related issues. It is recommended that women who are more than three months pregnant postpone their Hajj to another year.

Pregnant women who choose to go to the Hajj must be fully immunized. Pregnant women should pay extra attention to their diet and drink plenty of water.

(Prof Mohammad Sultan Khuroo is a renowned gastroenterologist. He can be mailed at khuroo@yahoo.com. mohammad.khuroo@gmail.com)

DISCLAIMER: The views and opinions expressed in this article are the personal opinions of the author.

The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.

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