Treating Muslim patients
Professor Aziz Sheikh and Professor AR Gatrad outline practical issues that may be important in dealing with Muslim patients
Ethnic and religious pluralism is now a key defining characteristic of many European societies. One of the most pressing challenges now facing civic and social institutions in these countries is negotiating how best to cater for the needs of their minority communities.
It needs to be appreciated that British Muslims are an ethnically, linguistically and culturally heterogeneous group, this being reflected, for example, in 2001 census data that showed there is now a significant Afro-Caribbean and white Muslim presence in Britain.
But despite this diversity, Muslims share a religious narrative that has the potential to impact greatly on health and health care delivery.
Religious communities tend to have a number of highly symbolic rites of passage at the extremes of life. There are a number of Muslim birth customs that offer profound insights into Muslim society. The most important customs GPs and their teams need to be aware of are:
· Adhan: This is the call to prayer incorporating the testimony of faith ('There is no deity but Allah and Muhammad is His Messenger') that is whispered into the ear of the newborn and for those providing home deliveries it is important that parents be offered a few minutes to perform this important ritual as soon as possible after delivery.
· Taweez: This is a string pouch containing religious scriptures that is sometimes tied around the baby's neck or wrist in an attempt to help overcome illness and/or ward off evil. This should be treated with respect and only removed if absolutely necessary.
· Circumcision: Muslims have their male children circumcised, typically within the first few weeks of life. Some health authorities now offer NHS circumcision to religious minorities, so reducing the health risks of secondary infection, haemorrhage and scarring that may occur when the procedure is performed privately. But difficulties in having the procedure performed on the NHS means most will have to resort to the private sector.
Parents need to be advised to delay the procedure in the event of prolonged jaundice or if there are genital deformities such as in infants born with hypospadias because of the risk of prolonged bleeding in the former and the need to use the foreskin for restorative surgery in the latter.
Estimates suggest up to 90 per cent of adult Muslims fast during the lunar month of Ramadan. This entails complete abstinence from food, drink, oral ingestion of drugs and smoking throughout daylight hours (dawn to sunset).
Pregnant and nursing mothers and those who are unwell are exempt from fasting if the practice is thought liable to have an adverse effect on health.
Patients may seek medical help in deciding whether or not they should fast and detailed guidance is now available (see 'further reading'). In the majority of those with chronic disorders in our experience it is possible to safely facilitate fasting by altering drug regimens, such as switching to once-daily
preparations of inhaled corticosteroids for asthma or slow-release preparations for managing hypertension or angina.
Headaches resulting from dehydration are common in the first few days of fasting, particularly when Ramadan falls in the summer months, and patients should be advised to increase fluid intake. Dyspepsia is also common, largely because of the increased consumption of high-calorie fatty foods by some Muslims.
Medication with porcine and alcohol-derived ingredients
Any food or drink that contains these products is not allowed and therefore should not be offered to a Muslim. But if there is no alternative available for a medication then the rule is 'necessity allows the prohibited'.
CFC-free inhalers for asthma may use ethanol and many patients, if they become aware of this, are likely to prefer an alternative non-CFC preparation. But there should really be no objection to vaccines such as MMR, which is porcine-derived only the ingestion of pork is prohibited.
There are two main issues that may arise with contraception. Irreversible methods of contraception (sterilisation) are generally viewed as prohibited. Women may prefer to have their periods postponed if they are likely to coincide with a major religious festival/event such as journeying to Mecca on the Hajj.
This is easily achieved using norethisterone or 'bicycling' in those on the oral contraceptive pill, that is, taking two packets without a break.
Many Muslim jurists have now outlawed cigarette consumption on the grounds that the practice violates one of the central tenets of Islamic law, namely the prohibition against 'killing or harming oneself'.
More enlightened health authorities and clinicians have been able to use such advances in thinking to deliver health care, in the shape of smoking cessation programmes for example, in a religiously sensitive context, thus working in
tandem with local community organisations.
Similar innovative programmes now exist with relation to drives to address drug and alcohol addiction problems within the Muslim community, for use of these
agents is also prohibited on the grounds that they adversely affect mental integrity.
Research suggests the majority of Muslims wish to die at home. There are a number of factors that contribute to this desire, including concerns around difficulties in receiving appropriate pastoral care, problems with having relatives and friends present at the time of death and the wish to avoid a postmortem examination. Where possible, this wish should be facilitated.
Irrespective of the place of death, almost all Muslims will wish for a prompt burial and any attempts by GPs and members of their teams to expedite the process of issuing a death certificate are usually greatly appreciated.
Most of us will have received little or no training in transcultural medicine; any instruction that has been received will often be in a specifically ethnic context. Religion and health have an intricate and intriguing inter-relationship for many people, and particularly for those whom life is not coloured by the post-renaissance dichotomy of sacred and mundane.
Equipped with skills of patient-centredness, empathy and a basic understanding of the dynamic interface between faith and health, it is possible to work with and engage minority communities in the task of delivering care that is both culturally competent and sensitive.
Aziz Sheikh, Department of Community Health Sciences, University of Edinburgh, chairs the research and documentation committee of the Muslim Council of Britain
AR Gatrad, consultant paediatrician, Manor Hospital, Walsall, is an adviser to the Muslim Council of Britain
Sheikh A, Gatrad AR (eds). Caring for Muslim patients. Oxford: Radcliffe, 2000