The Golden Age of the Social Determinants of Health – the era of the Prophet and the Righteous Four

Basem A Khalil MRCS(Ed) FRCS (Paediatric Surgery)Consultant Paediatric and Neonatal Surgeon

Clinical Head of Department of Paediatric SurgeryRoyal Manchester Children’s Hospital

Manchester, UK

What is Health?

Health is defined as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity

World Health Organization

What is Medicine?

The science or practice of the diagnosis, treatment, and prevention of disease

Oxford Dictionaries

Comparison

• Health– a state of complete physical, mental and social

well-being and not merely the absence of disease or infirmity

• Medicine– the science or practice of the diagnosis,

treatment, and prevention of disease

The Social Determinants of Health

Importance of social determinants to Health

Health in Pre-Islamic Arabia Prior to the advent of Islam

• “the state of health of the Bedouin and the urban dwellers must have been very bad”

Manfred Ullman

I totally and wholeheartedly agree

The Islamic Caliphate

• The Caliphate is a State whose constitution is based on the Qur’an and the Traditions of the Prophet Mohammed (known also as the Sunnah)

• Three eras:– The Era of the Righteous Four (632CE – 661CE)– The Ummayad Era (661CE – 750CE)– The Abbasid Era (750CE – 1258CE)

Principles of Health Care according to the Qur’an and the Sunnah

• The Welfare State

• Health Promotion

• Preventive Medicine

• Medical Therapy and care of the sick

• Health Care Legislation

Medina – the First Islamic Welfare State

Health Promotion 1

• “Two bounties regarding which many people cheat themselves: health and free time.”

• “He who reaches the morning while health is still in his body, safe in his residence and having his day’s sustenance will be as if the entire life of this world was granted to him.”

• “Ask God for certainty of faith and good health, for indeed no one will have a better possession after certainty of faith than good health”.

• The Prophet Mohammed as reported by Bukhari, Tirmidhi and Ahmad.

Health Promotion 2

• Sanitation/Environmental Protection• Personal Hygiene• Oral and dental care• Prevention of sexually transmitted diseases• Dietary advice• Physical exercise• Ban on alcohol and intoxicants• Quarantine measures

Snapshot comparisons

• “Had it been that I feared for making things difficult for my community, I would have commanded them to use the Siwak before every prayer” (Al-Bukhari) (Muslim).

Siwak

• Made from a plant called Salvadora persica• Swedish study (2004)

– Significant reduction of gingival and plaque indices

– A. actinomycetemcomitans • Reduced by Siwak• Not reduced by modern toothbrushing• Significantly reduced dental caries

(al-Otaibi, 2004)

Projected Impact

Snapshot Comparisons

Snapshot Comparisons (Contd)

Snapshot Comparisons (Contd)

The Hand washing technique commanded by the Prophet

Mohammed

NHS recommendations ( The Seven Steps of Hand

washing)

Washing the full hand including the palm Palm to palm

Washing the full hand including the dorsum Palm to dorsum

Making sure water runs between all the fingers Palm to palm with fingers interlocked

As above Backs of fingers to opposing palms

As above Fingers to thumb

Washing the fingers including the tips Tips of fingers

The wrist must be included in the ablution Washing of wrist

Snapshot comparisons (Contd)

Snapshot Comparisons (contd)

• Alcohol:– Causal factor in 60 major diseases

– WHO, 2011

– 2.5 million deaths a year (more than HIV & TB)– WHO, 2011

– In the UK, costs the National Health Service 3.3 billion pounds a year

– Scarborough et al, 2011

Snapshot comparisons (contd)

• The WHO world alcohol consumption map (WHO, 2005)

Dietary advice and Physical Exercise

“The son of Adam never fills a vessel worse than his stomach. The son of Adam only needs a few bites to sustain himself, but if he insists, one third should be reserved for food, another for his drink and the last third for his breathing”

(Ahmad).

Physical Exercise

“Any action without the remembrance of God is either diversionary or heedlessness excepting four acts: walking from target to target (as in archery practice), training a horse, playing with one’s family and learning to swim”

(Ibn Al Qayyim Al Jauziyah).

Physical Exercise

• The Prophet encouraged wrestling and racing. Aisha his wife reported:

“I raced with the Prophet and I beat him. Later when I had put on some weight, we raced again and he won. Then he said, ‘this cancels that (referring to the previous race)’”

(Al-Bukhari).

Projected Impact

• Evidence based practice in physical activity promotion within primary care has emerged

(Crone et al., 2004)

Financial Impact of Obesity and Physical Inactivity

Medical Therapy and care of the Sick

Legislation

• “Those who practice Medicine, but are not knowledgeable in this profession are responsible for their actions”.

– The Prophet Mohammed (Abu Dawood, Ibn Majah, Al Nisai)

• “A doctor who is proficient in his field and acts responsibly and treats a patient in a way allowed by the religion and has the sick person’s consent, then commits a mistake, he is not liable for this mistake”

– Ibn Al Qayim

The Righteous Four (632CE – 661CE)

• Abu Bakr: 632CE – 634CE

• Omar Ibn Alkhattab: 634CE – 644CE

• Uthman Ibn Affan: 644CE – 656CE

• Ali ibn Abi Talib: 656CE – 661CE

Abu Bakr

The Winter Benefits: importance to Health

The Winter Benefits: Importance to Health

Omar ibn AlKhattab: The Welfare State

• Benefits to the disabled• Unemployment benefits• Benefits to the poor and needy• Benefits to abandoned children• Benefits to orphansAccording to records, at one point there were

700,000 people in the Government’s Benefits Records

Alnumani, 1998

Omar ibn AlKhattab: Welfare State II

Omar ibn AlKhatab: Food provision

• The General Kitchens– Large kitchens in the cities/provinces– Provided cooked food for the poor/needy

• The Highway Rest Houses– Houses of Flour (Dar al Daqeeq)– Provided for travellers free of charge

Omar ibn AlKhatab:Water Supply

• Water channels in Iraq– Water channels to bring water from the main

rivers nearer to people’s homes

• Water channels in Egypt– Construction of dams

• Water wells on the pilgrims routes

Snapshot Comparisons

• Food supply:

“individuals experiencing food insecurity exhibited clinical signs such as poor health status, poor diabetes and chronic disease management and poor cognitive function” (Kregg Byers CM et al, 2010, University of Pittsburgh).

Snapshot Comparisons

• The Children and Women’s benefits scheme – the US experiment:

– Temporary assistance for Needy Families (TANF Scheme) – 1996

– Limited aid for 5 years only– After 5 years subsidy ends even if the women and children

are still below the poverty line– 64% of TANF leavers were unemployed because of their

own poor health– 56% of TANF leavers were unemployed because of their

own child’s heath

The TANF experiment (contd)

• Poor maternal health was associated with need for cash assistance and health insurance– Romero et al, 2002

• Leaving these families behind without a subsistence safety net creates an urgent need for new ways to support their health – Hildebrandt E, 2009

• Social policies promoting employment will fail if they do not address the health needs of poor women and children – Romero et al, 2002

Omar: Disaster management

• The Famine of Arabia – the year of Ramada (639CE)

• Affected the whole Arabian Peninsnula

• 60,000 refugees arrived at the Capital city of Medina

• The Caliph ordered an emergency set up of more public kitchens

The Year of Ramada (contd)

• Orders were sent to all provincial leaders in the Peninsula to set up aid camps with general kitchens

• Camps were divided appropriately

• Officials scoured the camps to cater for the refugees

• Food was sent to the homes of those who could not come to the camps

The Year of Ramada (Contd)

• As the famine raged:– Multinational trigger response• Orders to the Governor of Greater Syria

– 4,000 camel loads of food

• Orders to the Governor of Egypt– 1,000 camel loads of food

• Orders to the Governor of Damascus– 3,000 camel loads of food

• Orders to the Governors of Iraq– 1,000 camel loads of food

The Year of Ramada (contd)

• Further multinational trigger response:– Water Channel to be constructed from the River

Nile to the Red Sea– 69 miles long– Completed within 6 months– 120,000 Egyptians worked on the construction

paid by the State– 20 ships laden with food aid arrived by channel &

sea to the famine stricken Peninsula

Casualties

• After 9 months of famine, the drought ended

• State officials helped refugees to return to their homes

• Rehabilitation of the Peninsula

• Total deaths in the 9 month period:– 20,000.

Snapshot Comparisons

The Plague of Emaus

• Post famine – 639CE

• Started in Emaus near Jerusalem

• Caliph meets with his Governor on the border

• Islamic Law enforced Quarantine is undertaken

• Greater Syria is Quarantined from the rest of the then known world

The Plague of Emaus (Contd)

• The Governor of Syria dies in the Plague

• His deputy dies in the Plague

• The Governor of Egypt takes leadership– Moves population to higher grounds– Plague dies down

• Casualties:– 25,000

Post Plague

• Caliph enters Greater Syria

• Rigorous registration of those affected is undertaken

• State stipends given to those affected

• Rehabilitation of Greater Syria

The “Higher Grounds”: Scientific explanation

Simple:

Break in the life cycle of Yersinia pestis

Snapshot Comparisons

• The Black Death in Europe – 1348 – 1350• 75 – 200 million deaths• Jews blamed for poisoning wells– 1349: communities in Mainz and Cologne

destroyed– Strasbourgh: 2000 Jews killed– By 1351: 60 major and 150 smaller Jewish

communities had been destroyed

Snapshot Comparisons

• The Plague of Emaus:

– No ethnic minorities targeted

– Muslims and non-Muslims came under the protection of the State

Conclusion

The Qur’an, the Prophet and the Righteous Four did nothing to change the “miserable situation of the health of the Arabs” that existed prior to Islam”

Manfred Ullman

I totally and wholeheartedly disagree

Thank You