A review of research relating to Hajj and the impact of the Hajj on mental wellbeing. Presentations were delivered by the following experts on the following topics: - Javid Patel, Chair of the NHS Improvement Muslim Network, who spoke about the connection between Hajj and mindfulness - Dr Zavid Chariwala, GP for British Hajj Delegation, who spoke on common mental health conditions found in the Hajj - Rashid Mogradia, CEO for Council of British Hajjis, who gave a comprehensive review of the Hajj in 2018 and the health challenges on the ground - Dr Shuja Shafi, Secretary General for Muslim Council of Britain, who provided an overview on the work he has been doing around vaccinations and infection outbreaks associated with the Hajj - Ian Walker, Mental health consultant at Public Health England, gave an overview of the research around Hajj and mental health and how Hajj has a positive impact on mental wellbeing - Clare Lyon-Collins, Mental health lead for NHS Improvement, provided a rich background on mental health and the distinction between mental health and mental illness as well as mental health awareness

1. Health and Hajj
Musli m
Network
He al th
C ollabor ati on

2. HAJJ & mental HEALTH
P u b l i c H e a l t h E n g l a n d
N H S I m p r o v e m e n t
D e p a r t m e n t o f H e a l t h
M U S L I M N E T W O R K
C O L L A B O R A T I O N

3. WELCOME
N u z h a t A l i
C h a i r
M u s l i m N e t w o r k
P U B L I C H E A L T H E N G L A N D

4. WHAT IS HAJJ?
J a v i d P a t e l
C h a i r
M u s l i m N e t w o r k
N H S I M P R O V E M E N T

5. The pilgrimage to Makkah,
in Saudi Arabia, is the fifth pillar of the
Islamic faith which unites millions from
across the globe.
WHAT’S
IT ALL
ABOUT?

6. Hajj is
about
being
mindful of
our
Creator

7. Commit to
re-centre
your life
Your purpose is to
live a life
following
God’s guidance

8. Recognise you
will
ultimately
return back to
your Creator
on the Day of
Judgement

9. Equality of humanity & belonging
… an Arab has no superiority over a non-Arab nor a non-Arab has any superiority over an
Arab; also a white has no superiority over a black, nor a black has any superiority over a
white - except by piety and good action. [PROPHET MUHAMMAD, peace be upon him]

10. “… the awareness that emerges through paying attention:
• On purpose,
• In the present moment
• Non-judgmentally to
see things as they are.”
- Jon Kabat-Zinn
MINDFULNESS

11. The need for more resources & awareness
Findings from study of 136,000 Indian pilgrims:
q Incidence of mental morbidity lower than expected, attributed to “highly
positive mental state provided by spiritual experience in Indian pilgrims.”
q 83% pilgrims reported not being told about the “actual” difficulties
involved or details of rituals during Hajj
q 93% of those treated for mental illness had no previous history of mental
symptoms
q Most common symptoms were apprehension (45%), sleep (55%), anxiety
(41%) and fear of being lost (27%)
Khan, S.A., Chauhan, V.S., Timothy, A., Kalpana, S. and Khanam, S., 2016. Mental health in mass gatherings. Industrial psychiatry journal, 25(2), p.216.

12. Just the thought of performing
this life changing journey can be
daunting too

13. The Hajj in numbers
3 million people from
over 180 countries
- 25,000 of which are
from the UK
Health services
stretched
Symptoms show once in
home countries

14. REQUIRES
EFFOR T &
SAC RIFIC E &
PATIENC E
Heat
Travel
Congestion
Facilities

15. 15
Events focusing on
Hajj & health
Hajj resources
for pilgrims &
tour operators
Hajj research &
public opinion
The Muslim Network Collaboration & Hajj

16. Faith addresses healing & health
Prophet Muhammad (PBUH)
“There is no DISEASE
that God has created,
except that HE has
created it’s
TREATMENT
Prayer
“Oh God, I take refuge in You
from anxiety and sorrow,
weakness and laziness,
miserliness and cowardice,
the burden of debts and
from being overpowered by
people.”

17. 17
Al-Balkhi
850 – 934 CE
Al-Raazi (Rhazes)
854 – 925 CE
Avicenna
980 – 1037 CE
Centuries of Muslim clinical contribution
shaping mental health practice

18. 18
Rai si ng awareness
and
e nc ou raging others
to perform this
remarkable journey
Work wi th us to
produc e
more Ha jj and
health
resourc es
Nhsi.Muslimnetwork
@nhs.net
Sig n up to our
n ewsl etter
You can get involved through …

19. 19
THANK YOU

20. HEALTH AT HAJJ
AND UMRAH
D r S h u j a S h a f i
C H A I R
M u s l i m C o u n c i l o f B r i t a i n
R e s e a r c h & D o c u m e n t a t i o n
c o m m i t t e e

21. Communicable
Ø Respirator y
Ø Viral, bacterial
Ø Tuberculosis
Ø Emerging viral
infections
Ø AMR, BBV
Ø Major outbreaks
Major health challenges associated with the Hajj
Non-communicable
Ø Diabetes
Ø Hear t-related illness
Ø CVD, hyper tension
Ø Underlying
conditions
Ø Pre-existing
conditions

22. The need for shared responsibility
• Shared concern & ownership between host country (Saudi
Arabia) and pilgrim’s country
q Collective effort between healthcare professionals, group
leaders, community and pilgrims
q Preventative measures required for:
q Protection of pilgrims
q Protection of staff/workers
q Returning pilgrims and the communities they will be
returning to

23. The ideal preparation for the pilgrim…
q GP/nurse assesses pilgrim’s health requirements and
advices on preventative measures reflecting the physical
exertion required at Hajj.
- This includes the cessation of monthly periods for women
q Pilgrim to ensure appropriate health and travel insurance obtained
q Health resources to provide more information on health risks
q GP provides details on post-Hajj checks

24. For pilgrims suffering from diabetes…
q Approx. 20% of Muslims in the UK suffer from diabetes (higher in older
people)
q Advise for the pilgrim with diabetes:
q Inform your GP/nurse that you’re attending the Hajj
q Request an annual review of diabetes
q Seek medical advice on medication change to reflect the heat and
exhaustion associated with the Hajj
q Seek advice on vaccination
q Seek advice on what to do if condition gets worse during the Hajj

25. Infection outbreaks

26. MCB’s health leaflet for pilgrims

27. Meningococcal vaccine coverage
Lancet , 2007: 368:p1343, April 21
q British pilgrims, aged 14–81 years, all said they had been vaccinated
q Of the 109 Pilgrims from Saudi Arabia (aged 16–85 years):
§ 70 (64%) vaccinated,
§ 35 (32%) had not,
§ 4 ( 4%) were unsure
q Immunisation rates among:
§ Expats – 43%
§ Native Saudis – 78%
§ Pilgrims from Mecca & Jeddah – 50%
§ Rest of Saudi Arabia – 71%
q Lower vaccine coverage across Saudi Arabia is concerning suggesting a
need for a regular immunisation audit

28. Getting it right at the Hajj

29. Established national programme
q Over 1,400 ‘partner clinics’ established
q Pharmacies include: Co-Op, Superdrug, Tesco,
Lloyds1
q Programme offered for NHS commissioned
pharmacies in the appropriate demographic areas
q GP Practices, travel clinics, community vaccination
clinics
q Endorsed by RPS and RCGP
q Also endorsed by: MCB; MINAB; MDDA; CoEJ
q Featured in the BMJ 20132
q Promoted across >550 mosques and Hajj travel agents
1. Data on file: Participating PHP Clinics. Novartis Vaccines and Diagnostics Limited, December 2012
2. British Medical Journal, Minerva, 18 September 2012, BMJ 2012;345:e6200, http://www.bmj.com/content/345/bmj.e6200?variant=full-text&rss=1 (accessed December 2012)

30. Hundreds of pilgrims vaccinated at local Mosque
Participating MCB clinics now being supported to deliver the service

31. 2010 500
2011 1,200
2012 12,000
2013 20,000+
Uptake of vaccination
Diary: RTI prevalence

32. Field studies conducted
q Samples taken and tests done on the spot
q If tests suggested influenza then medicine prescribed
q Further tests performed later on to identify causes
q Trends analysed for future procedures/research
q Important: we cannot eliminate pilgrim cough but we can
reduce
q 256 patients investigated during various stages of Hajj including
return to UK
q 9% shown to be suffering from Flu A while 6.25% suffering from
Flu B

33. Field studies conducted

34. SERVING THE
PILGRIMS
D r Z a v i d C h a r i w a l a
G P , B r i t i s h H a j j D e l e g a t i o n
p r e v i o u s l y f u n d e d b y t h e
F o r e i g n C o m m o n w e a l t h
O f f i c e

35. THE VOICE OF
BRITISH
PILGRIMS
R a s h i d M o g r a d i a
C E O
C O U N C I L O F
B R I T I S H H A J J I S

36. Rashid Mogradia
Founder & CEO
CBHUK
Health & Hajj
5th September 2018
Wellington House, London

37. Hajj is a testament that people of all colours & backgrounds
regardless of social standing can
co-exists in peace, harmony and unity.
– Rashid Mogradia
Founder & CEO, CBHUK.org

38. • The Hajj Journey
• Health Issues
• Support for British Pilgrims
• Hajj 2018 – Highlights
• Opportunities
Hajj 2018

39. Makkah to Mina: 8 km
Mina to Arafat: 14.4 km
Mina to Muzdalifah: 3 km
Makkah to Arafat: 22.4 km
Saudi Arabia
Temp in August can
hit up to 45°C

40. About CBHUK
• Leading National Hajj & Umrah Charity
• Est. 2006 – Over 12 years of consistent service
• Winners of the Best Community Group 2018 at the British Muslim Awards
2018
• Finalist & Runner-Ups at the Fusion Awards 2018
• Listed in the Muslim Power 100 (2018) as Trailblazer
• Co-Founder & Secretariat to the APPG Hajj & Umrah
• Pioneers in Community Vaccination Clinics & Hajj & Umrah Training Seminars
• Over 30 Events & Clinics delivered annually across UK

42. The CBH Hajj Journey
Pre Hajj
Vaccination /
Pre-Existing
Illnesses
Booking / Selecting
a Tour Operator
Pre Travel
Expectations?
Travel in KSA
2m + People /
Crowds
Expectations &
Local Experiences
Spiritual &
Health Issues

43. Health issues 2018

44. Mental health at Hajj
• Pilgrimage can be stressful, even for those with resilient mental health
• Heavy Crowds
• Being Told what to do (Pilgrim Safety / Crowd Management)
• Take medications regularly
• Travel companion knows of history and how to manage
• Ruqya / Prayer
• Peace and tranquillity in the Holy Mosques in Makkah and Madinah will
help individuals.

45. Key highlights 2018
• Hajj Doctor on Call Service
• Provided Welfare Support
• Prevented a Public Health Outbreak
(UK Group with 25PAX reported Projectile vomiting
and diarrhoea)
• Support for Hajj Fraud Victims

46. Health Screening by
Ministry of Health of
Arriving Pilgrims at
Madinah Airport

47. Health Education &
Health Checks
SMAV & CBHUK
with Elsawy Travel
(London) Group.

48. On the ground
collaboration with
Ministry of Health,
SMAV and CBHUK
Al Noor Hospital, Makkah

49. 49
CBH presence at UK camps

50. 50
The reward for an accepted Hajj is
nothing less than paradise.
Prophet Muhammad (Peace be upon him)
Wishing you all
an
accepted Hajj

51. THANK YOU
Please Support Our Work
www.cbhuk.org/donate

52. HAJJ RESEARCH
STUDIES
I a n W a l k e r
G L O B A L M E N T A L H E A L T H &
W E L L B E I N G T E A M
P u b l i c H e a l t h E n g l a n d

53. MentalHealthinMassGatherings
IanWalker
SpecialtyRegistrarinPublicHealth

54. Research on mental health and the Hajj
q Overall - likely benefits to an individual’s wellbeing although this is mostly
based on anecdotal evidence and this area needs further research.
q Study of Iranian students (before and after, n=350) found increased levels
of wellbeing and meaning in life on return from the Hajj.
Bakhtiari M,Masjedi Arani A, Karamkhani M, Shokri Khubestani M, Mohammadi H. Investigating the Relationship between Hajj
Pilgrimage and Mental Health among Sharif University of Technology Students. J Res Relig Health. 2017; 3(2): 78- 87.
q Study in Pakistani pilgrims (n=1,605). Found significantly worsened mental
health and wellbeing in the Hajjis, mostly in women, although this reflected
the more favourable and accessible conditions in Hajj compared to Pakistan
Clingingsmith, David, Asim Ijaz Khwaja, and Michael R. Kremer. 2009. Estimating the impact of the Hajj: Religion and tolerance in
Islam's global gathering. Quarterly Journal of Economics 124(3):

55. q There are risk factors for poor mental health -
• unfamiliar environment
• heat
• overcrowding
• sleep deprivation
• physical exertion
• limited dietary intake
• spiritually demanding
q Unfortunate incident of a person committing suicide in June 2018
in Mecca’s Grand Mosque, although the circumstances were
unrelated to the pilgrimage
Research on mental health and the Hajj

56. Mental health of Turkish pilgrims
Study of 130,000 Turkish Hajj pilgrims in 2008 (Turkish Mecca
Hospital)
q 294 patients presented to the psychiatric service (0.2%)
q Anxiety (38.4%), mood disorders (22.1%), sleep disorders
(11.2%), mood disorders (5.6%)
q Most common symptoms recorded were discomfort (70%), poor
sleep (55%), anorexia (35%), ‘whining’ (30%) and fatigue (28%)
q 60% had a previous psychiatric history, 40% male, 77% low
education, 71% had not been abroad before
Özen, Ş. 2009. Sociodemographic characteristics and frequency of psychiatric disorders in Turkish
pilgrims attending psychiatric outpatient clinics during Hajj. Dicle Med J Cilt / Vol 37, No 1, 8-15

57. Mental health of pilgrims at a hospital
Study in 2005 in 2 week period of Hajj (Al Noor Specialist Hospital, Makkah)
q 92 patients presented to the psychiatric service
q Anxiety disorders 34%, mood disorders 22%, psychotic disorders 20%
q Most common symptoms - behaviour 65%, mood 63%, sleep 59%, thought
disordered 29%
q Country of origin: 48% Saudi Arabia, 17% other Arab Countries, and 35%
non-Arabic speaking countries
q No previous psychiatric disorders 52%
Masood K, Gazzaz ZJ, Ismail K, Dhafar KO, Kamal A. Pattern of psychiatry morbidity during Hajj period at Al-
Noor Specialist Hospital. Int J Psychiatry Med 2007;37:163-172

58. Risk factors
Occurrence of most illness was stress induced:
Ø Cannot change the event itself
Ø Mitigations are possible to limit the stress
Ø Screen pilgrims for stressful life events?
At least 50% had no previous mental disorder:
Ø Screening in UK before Hajj has limited value
Ø Psychiatric ser vices are well developed (countr y-specific
health missions and KSA health ser vice)
Ø Organisers and tour operators have responsibilities

59. Risk and protective factors
Mitigations - preparation:
Ø Aware of the challenge and exer tion of performing the
Hajj (a detailed understanding of what is involved).
Ø Physical fitness and healthy diet in months before Hajj
Mitigations – suppor t while on Hajj:
Ø Family/close friends
Ø Competent tour staff
Ø Realistic itinerar y for visit
Ø Professional health ser vices during Hajj
Ø Asking help from fellow pilgrims
Ø Consider less crowded times and areas

60. Advice for those with pre-existing mental
health conditions
• Seek advice from GP or psychiatric professional before booking Hajj
• Continue prescribed medication while on Hajj
• Have a relapse plan developed especially for the Hajj
• Travel with trusted family/friends who are aware of previous illness
• Make sure family/friends attending Hajj are aware of the relapse
plan (early signs and what to do)
• Self-monitor for signs of any emerging symptoms
• Avoid the most crowded and noisy aspects of the Hajj
• Undertake a realistic itinerary during the whole visit

61. Psychological impact of a crowd
Discredited traditional view
People in crowds lose their sense of self, lose their sense of judgement, and
become capable of the most extreme actions
Social identity theory
People perceive a common group membership and assume a shared social
identity in a ‘psychological crowd’. This leads to –
1. A cognitive transformation.
2. A relational transformation.
3. An emotional transformation.
A study of 1,194 pilgrims attending Mecca in 2012 found that people felt safer
and perceived the crowds to be less dangerous when they strongly identified
with others in the crowd. This was due to the perception that others in the
crowd were supportive.
Alnabulsi H, Drury J (2014) Social identification moderates the effect of crowd density on safety at the Hajj. Proc Natl
Acad Sci 111(25):9091–9096. https ://doi.org/10.1073/pnas.1404953111

62. 1. Examples of negative impact on mental health are rare
2. Positive vs negative impact
3. Planning is ver y impor tant
4. Expectations before the event
5. Perceptions of other pilgrims
Summary

63. Dr Shuja Shafi,
Chairman for MCB
Research &
Documentation
Committee
Dr Zavid
Chariwala
GP from the
British Hajj
Delegation
Ian Walker,
Public Health
England Global
Mental Health and
Wellbeing
Rashid
Mogradia
CEO for Council of
British Hajjis &
APPG Secretariat
Clare Lyons-
Collins, NHS
Improvement
Mental Health and
Policy Lead
Guest
panelists

64. MENTAL HEALTH
C l a r e Ly o n s - C o l l i n s
M E N T A L H E A L T H & P O L I C Y
L E A D
N H S I m p r o v e m e n t

65. Context
q NHS spends £11.48 billion on mental health annually.
q 1 in 4 will experience a mental health problem at some point in their lives
and 1 in 6 adults will be mentally unwell at any given time. (No health
without mental health, 2011)
q Sickness absence due to mental health problems costs the UK economy
£8.4 billion a year and also results in £15.1 billion in reduced productivity.
q Largest single cause of disability in the UK representing 23% of the total
burden of ill health.
q Total cost of mental health in England is estimated to be around £105 billion
and it has been estimated that the cost of health services to treat mental
illness could double over the next 20 years

66. What is mental health?
What does the term mental health mean to you? Discuss in pairs
Mental health is:
‘…the emotional and spiritual resilience which allows us to enjoy life
and survive pain, disappointment and sadness. It is a positive sense
of well-being and an underlying belief in our own and others’, dignity
and worth’.
- Mental Health Promotion: A quality framework (1997).
NOTE: Good mental health is not just the opposite of
mental illness.

67. What are mental health problems?
Mental health problems are disturbances in the way people
think, feel and behave.
There are different types of mental health problems.
Common ones are depression and anxiety disorders.
(frequently called ‘common mental health problems/illness).
Less common are schizophrenia and bipolar disorder (manic
depression).

68. Depression
• Causes people to experience depressed mood, loss of interest or
pleasure, feelings of guilt or low self-worth, disturbed sleep or
appetite, low energy, and poor concentration.
• A person suffering from depression will experience intense
emotions of anxiety, hopelessness, negativity and helplessness,
and the feelings stay with them instead of going away.

69. Signs and symptoms
A person who is clinically depressed will have at least
two of the following symptoms for at least two weeks
• An unusually sad mood that does not go away
• Loss of enjoyment and interest in activities that
used to be enjoyable
• Lack of energy and tiredness
People who are depressed can also have other
symptoms such as:
Loss of confidence in themselves or poor self
esteem, feeling guilty, difficulty concentrating,
moving more slowly, difficulty sleeping, loss of
interest in food, changes in eating habits may lead
to either loss of weight or putting on weight.
https://www.youtube.com/
watch?v=XiCrniLQGYc

70. What is an anxiety disorder?
Everybody experiences anxiety at some time. It’s a
natural response, useful in helping us to avoid
dangerous situations and motivating us to solve
everyday problems. Anxiety can vary in severity from
mild uneasiness through to a terrifying panic attack.
q An anxiety disorder differs from normal anxiety
in the following ways:
q It is more severe
q It is long lasting
q It interferes with the person’s work or relationship
Anxiety can manifest itself in a variety of ways –Physical,
Psychological, Behavioural

71. Pychological
• U n r e a l i s t i c
• M i n d r a c i n g
• D e c r e a s e d m e m o r y a n d
c o n c e nt r at i o n
• D i f f i c u l t y m a k i n g
d e c i s i o n s
• I r r i t a b i l i t y , i m p at i e n c e ,
a n g e r
• C o n fu s i o n
• R e s t l e s s n e s s o r f e e l i n g
o n e d g e
• T i r e d n e s s
• U nw a nt e d , u n p l e a s a nt
r e p et i t i v e t h o u g h t s
Physical
• Pa l p i t at i o n s , c h e s t
p a i n , r a p i d h e a r t b e at ,
f l u s h i n g
• H y p e r v e nt i l at i o n ,
s h o r t n e s s o f b r e at h
• D i z z i n e s s , h e a d a c h e ,
s w e at i n g , t i n g l i n g ,
nu m b n e s s
• C h o k i n g , d r y m o u t h ,
n au s e a , v o m i t i n g ,
d i a r r h o e a
• M u s c l e a c h e s a n d
p a i n s
Behavioural
• Av o i d a n c e o f
s i t u at i o n s
• R e p et i t i v e c o m p u l s i v e
b e h av i o u r e . g
e x c e s s i v e c h e c k i n g
• D i s t r e s s i n s o c i a l
s i t u at i o n s
• Ur g e s t o e s c a p e
s i t u at i o n s t h at c au s e
d i s c o m fo r t .
Symptoms

72. 72
Raise awareness
of mental health
issues
Suppor t mental
wellbeing of
individuals
Provide peer-suppor t
and learning
oppor tunities
Mental health first aid network

73. How can we help?
NHS Improvement intranet:
q MHFA resources
q Online self-help bookshelf
q Employee Assistance Programme
q Events – football, singing, walking, colouring…
q Team discussions
q One-to-one support
q MHFA Training
Is there more we can do?
Let us know your ideas?