BMJ  2007;334:74 (13 January), doi:10.1136/bmj.39072.347720.68

Feature

Head to head

Should Muslims have faith based health services?

¹ Division of Community Health Sciences, University of Edinburgh, Edinburgh EH8 9DX

At a time when many government and public bodies are recognising the importance of engaging with faith communities, Aziz Sheikh advocates that the UK should provide specific health services for Muslims. But Aneez Esmail argues that such services could enhance stigmatism

Muslims have the poorest overall health profile in Britain, but there are few faith centred initiatives aiming to improve health outcomes for our largest minority faith community. This reflects the general failure among academics, policymakers, and clinicians to appreciate the particular needs faith communities may have. There are important moral, political, and increasingly legal arguments underscoring the need to ensure equitable delivery of public services to all sections of society, including Muslims. In the short to medium term, these needs will most efficiently be met by taking several faith specific healthcare initiatives. The longer term goals, however, are to mainstream understanding of the importance of religious identity and develop appreciation of how this has the potential to interact with health and healthcare delivery.

Muslims in the UK

There has been a Muslim presence in Britain for almost half a millennium, yet Islam remains something of an enigma to most UK citizens.¹ Even among people involved with health policy and delivery it is surprisingly common to find Muslims being thought of as synonymous with Asians or Arabs. Positions such as these reflect a profound misunderstanding of a faith that has and continues to bind diverse groups of people.

The main Muslim migration to Britain came after the second world war driven by economic hardship in British colonies and workforce shortages. Most found employment as unskilled workers in the manufacturing industries, which explains why so many made their home in the inner cities (with all their associated problems). These economic migrants brought over their immediate and then extended families. Since the 1980s, however, migration has been largely for political reasons, with Muslims fleeing the war torn areas of northern and central Africa, the Balkans, Afghanistan, and the Middle East. Appreciable numbers of students and professionals have also come from the Indian subcontinent, the Arabian peninsula, and the Far East.

Ethnicity, religion, and self identity

Ethnicity and religion are important markers of self identity, and though often closely intertwined they are not synonymous. For many British Muslims, religious identity is the essential defining characteristic as it represents the prism through which they see and interpret the world. The 2001 Home Office Citizenship Survey—for example, found that for Muslims religion was a more important marker of identity than ethnicity.² Offering people only the choice of an ethnicity descriptor, as is the case when registering with a general practitioner or when attending hospital, is therefore inadequate and indeed inappropriate for many Muslims.

Racism—in both its direct and indirect (or institutional) forms—affects all British public services, including healthcare and there is now a welcome commitment to eradicate this evil.³ What is, however, far less well appreciated is that religious discrimination is also endemic.⁴ In many Western societies, animosity towards Islam dates back many centuries,⁵ but prejudice has risen since the bombing of New York's twin towers.⁶ What is needed is an appreciation that many Muslims will experience racial and religious discrimination and that both need to be tackled. My experiences suggest that the healthcare profession is still largely in denial about religious discrimination.

A question of faith

One of the main obstacles to making the case for Muslim services has been the lack of any reliable data. A question about religion was included in the 2001 census, albeit voluntary. However, a grassroots campaign helped to ensure a respectable completion rate (>92%), and a detailed picture of Britain's faith communities has finally begun to emerge.

We now know, for example, that there were 1.6 million Muslims in Britain in 2001 (more than all other minority faith communities combined) and that Muslims are the most ethnically diverse faith grouping in Britain. Muslims are predominantly congregated in the innercity slums, have the lowest household income, poorest educational attainment, and highest unemployment and experience more poverty than any other faith community.⁷ The limited health data show that Muslims are about twice as likely to self report poor health and disability as the population in general.

Need for faith specific initiatives

The proliferation of research highlighting the persistent health (and other) inequalities experienced by minority ethnic communities has led to important health and social policy initiatives.⁸ I believe that a similar course of action is now needed in order to better meet the need of faith communities.

We need to develop a better picture of the health profile and experiences of British Muslims. It is absurd that we do not, for example, know the perinatal mortality or smoking prevalence among Muslims.⁷ To facilitate this we need to encourage recording of religious affiliation in primary and secondary care. The first step would be to make standard codes available. While waiting for the data, several faith services should be initiated.

Male infant circumcision should be available throughout the NHS. Although a handful of NHS trusts provide it, most parents are forced into the poorly regulated private sector. Hospitals also need to do more to accommodate Muslims in other ways. Many, out of a wish to maintain modesty, may prefer to see a clinician of the same sex. Such choice is typically unavailable despite the higher numbers of women doctors in the NHS. Better access is required to prayer and ablution facilities for patients and staff in many hospitals.⁹ And Muslim "chaplains" need to be established to provide spiritual care.¹⁰

Another important service is to enable Muslims to avoid porcine and alcohol derived drugs. Currently national or local formularies do not routinely flag potentially objectionable drugs or provide advice on suitable alternatives.¹¹

Despite evidence that many people with long-term conditions modify their treatment regimens during Ramadan, many people do not get detailed advice on how to do this safely.¹² Similarly, we need better mechanisms for advising people on avoiding the health risks associated with the Hajj pilgrimage to Mecca, which is a religious obligation (and not a holiday).^{13 14} General practices should offer consultations before Ramadan and Hajj to inform their patients.

Although the problem has been repeatedly highlighted over many years, Muslims still often face unacceptable delays in having the bodies of deceased relatives released for burial.¹⁵ Training and reform of coroners' services is needed.

Change is unlikely to occur without adequate and appropriate representation of faith communities in positions of influence—be they government bodies, research charities, or NHS trusts. Such organisations must ensure that they include Muslims on their boards.¹⁶ As a first step voluntary monitoring should be tried, as is already often done for ethnic grouping.

There is, as far as I'm aware, currently not one British academic grouping specialising in researching the health needs of Muslims, partly reflecting difficulties with securing funding to support such research. Long term sustainability of possible service improvements is rightly dependent on rigorously proving that any changes produce the desired effects, and we need the wherewithal to ensure that this can happen.

---

Competing interests: AS chaired the research and documentation committee of the Muslim Council of Britain from 2002-6. He is currently principal investigator on a Scottish Executive supported grant investigating the end-of-life care needs of South Asian Sikhs and Muslims in Scotland.

References

1. Islamic Society of Britain. Attitudes towards British Muslims, 2002. www.isb.org.uk/iaw/docs/SurveyIAW2002.pdf#search=%22isb%20islam%20yougov%20poll%20%22
2. O'Beirne M. Religion in England and Wales: findings from the 2001 Home Office citizenship survey. London: Stationery Office, 2004.
3. Sheikh A. What's to be done about racism in medicine? J R Soc Med 2001;94:499-500.[Free Full Text]
4. Weller P, Feldman A, Purdam K. Religious discrimination in England and Wales. London: Home Office Research, Development, and Statistics Directorate, 2001.
5. Gunny A. Perceptions of Islam in European writings. Leicester: Islamic Foundation, 2004.
6. Ahmed AS. Islam under siege. Cambridge: Polity, 2003.
7. National Statistics. Focus on religion: health and disability. www.statistics.gov.uk/cci/nugget.asp?id=959
8. Department of Health. The race equality agenda of the Department of Health. London: Stationery Office, 2000.
9. Sheikh A. Quiet room is needed in hospitals for prayer and reflection. BMJ 1997;315:1625.[ISI][Medline]
10. Sheikh A, Gatrad AR, Sheikh U, Panesar SS, Shafi S. Hospital chaplaincy units show bias towards Christianity. BMJ 2004;329:626.[Free Full Text]
11. Gatrad AR, Mynors G, Hunt P, Sheikh A. Patient choice in medicine taking: religious sensitivities must be respected. Arch Dis Child 2005;90;983-4.
12. Car J, Sheikh A. Fasting and asthma: an opportunity for building patient-doctor partnership. Prim Care Resp J 2004;13:133-5.
13. Gatrad AR, Sheikh A. Hajj: journey of a lifetime. BMJ . 2005;330:133-7[Free Full Text]
14. Shafi S, Gatrad AR, Quadri SMH, Sheikh A. Vaccinations for Hajj. J R Soc Health 2006;126:68-9.[ISI][Medline]
15. Sheikh A. Death and dying—a Muslim perspective. J R Soc Med 1998;91:138-40.[ISI][Medline]
16. McNaught A. Health policy and race equality: an illusion of progress? J R Soc Med 2004;97:579-81.[Free Full Text]

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