We are delighted to publish this article authored by Professor Asif Ahmed and his colleagues Dr Alzahrani and Dr Varney.

Overview

 The year 2020 opened with the worldwide spread of a new coronavirus (SARS-CoV-2), which is characterised by high infectivity and significant mortality, especially in the elderly and those living with long-term conditions. Governments took unprecedented measures in peacetime to mitigate the spread and reduce fatalities. The solution to eradicating contagious diseases relates to human behaviour and adherence to preventive guidelines. Over 200 countries with nearly half of their societies adopting major religions and following religious practices suggest an important factor that control people's behaviour is their belief and the culture in those societies.  This commentary focuses on the potential role of religious communities in limiting the spread of a contagious infection. To prevent human-to-human contamination, the 10th Century Islamic scholar of Medicine, Ibn Sina, used a method of isolating people for 40 days as a means of limiting the spread of contagious diseases. This translated to ‘Quarantine’. The positive practices carried out by religious communities during this coronavirus outbreak is highlighted by religious communities and clerics giving a positive response to support governments in the cancellation of many religious gatherings and activities, particularly from an Islamic perspective. The coming together of communities of different faiths, races and nationalities under the banner of science, service and humanity has led to a high degree of global cooperation in the absence of any outstanding global leadership and shows what ordinary human beings can achieve when there is a common threat.

Background

Covid-19 is a highly infectious disease caused by a new coronavirus (SARS-CoV-2) first identified in Wuhan, China at the end of 2019. Despite the World Health Organisation (W.H.O.) declaring the outbreak a Public Health Emergency of International Concern at the end of January 2020, most of Europe and North America failed to get its citizens battle ready until on March 11, it was accepted as a pandemic. Within three months of China notifying the W.H.O., two million people were SARS-COV-2 positive and although, a quarter of them fully recovered from Covid-19, over hundred thousand people did not survive at the time this commentary was being written.

Governments that rapidly reacted and recognised the danger earlier and learned from the Chinese experience, managed to limit loss of life due to Covid-19 by deploying community testing, ‘contact tracing’ isolation and quarantine methods. Now, all governments are taking unprecedented measures in peacetime to mitigate the spread and reduce fatalities. Now, no one is advocating herd immunity without deploying effective and safe vaccination. The extensive measures are causing significant impact on local and global economies; disrupting social norms and increasing loneliness. Public health expert guidance during this crisis has focused on several key proven interventions: testing and isolation of infected individuals, social distancing, reinforcing of basic handwashing and respiratory hygiene and limiting travel to and from affected areas  (1).

Studies show that there are over 200 countries with nearly half of their societies adopting major religions and following religious practices. Approximately, 80 countries around the world have an official religion included in their constitutions and system of government. In the last Corona pandemic, W.H.O. confirmed that people's behaviour in adhering to preventive measures was the main solution to blocking and eliminating the crisis.

Islam and Biological Science

It may not be apparent to many but Islam has a tradition of following science. Muslim physicians and scientists contributions to biological science were greatest between the 8th and the 13th centuries, often referred to as the "Islamic Golden Age". Ibn Sina [Avicenna (980-1037)] and Al Razi (841-926) were the first to develop the field of Biological Sciences. Ibn Sina contributed to the development of the germ theory of disease and also discovered the contagious nature of tuberculosis and other infectious diseases. He introduced quarantine as a means of limiting the spread of contagious diseases. Later in the 14th Century, Ibn Khatima (1369) expanded upon these findings and was the first to discover bacteria and microorganisms (2).

Religious Practices

Many of the world’s great religions place religious emphasis on personal hygiene and food hygiene, and faith can play an important role in global efforts to promote hand hygiene[i], which in the current context is fundamental to reducing the impact of the coronavirus outbreak. Buddhism, Islam, Sikhism, Hinduism and Judaism all encourage the washing of hands before and after eating food, before prayer and before and after using the toilet. Christianity, on the other hand, in general does not place the same religious emphasis on handwashing.

In contrast to the benefits of faith related hygiene factors, there are also religion-related risks. Most world religions encourage individuals to congregate in places of worship to pray together, this is particularly important for those who are elderly or have health conditions. It is common for religious ceremonies to include physical contact, for example shaking hands, or kissing common religious items for example the Torah in synagogues. These present additional challenges in the context of the current need to socially distance individuals.

This commentary explores the religious and practical context of response to the new coronavirus through the perspective of Islam and the steps taken in Saudi Arabia in response to the emerging global outbreak. Over a quarter of the world’s population (1.8 billion) subscribe to Islam. It is a religion that significantly impacts on (based on Qur’an and Sunnah texts) all aspects of a Muslim’s life, including daily habits and behaviours (3).

Hygiene is a general behaviour that includes practices that promote mental, emotional and physical health as well as the social wellbeing of individuals (4). Islam’s rules of personal hygiene include washing hands, bathing, avoiding harmful foods, brushing teeth and clipping nails, washing the finger joints, all of which are related to personal and public health (5). Enjoying the highest level of personal hygiene is referred to in the Holy Qur’an (2:222) in a multitude of verses and also by the traditions of the Prophet Muhammad (pbuh), who told his followers ‘purity is half of faith’ (6).

Many people of faith begin their day with purity ritual. A Muslim starts his or her day with ablution, which is an excellent practice for limiting the spread of germs. As stated in the Holy Qur’an (5:6), ablution includes washing all exposed parts of the body including hands, feet, face, mouth and nose. This a practicing Muslim will do five times a day. This is consistent with the first guideline recommended by the W.H.O. for all members of society: to wash hands regularly and completely with soap and warm water (1).

Hygiene also includes some other simple actions with significant effects, such as covering the mouth when sneezing. Many epidemiologists believe that sneezing and coughing are effective means of spreading Covid-19. The W.H.O. recommends covering the nose and mouth with fabric when coughing or sneezing and disposing of the fabric immediately (1). This behaviour is considered proper etiquette within Islam and most Muslims practice it. As narrated by the Prophet (pbuh) and stated in the hadith, anyone sneezing is encouraged to cover the sneeze with a hand or clothing (7)(6).

Beyond the importance of individual hygiene, the protection of societies, including the most vulnerable members, is of utmost importance. Infected people should thus be isolated to reduce the spread of pandemic diseases. Consequently, the influences of self-isolation should not be ignored, and it is important to examine the factors that lead infected people to choose self-isolation. We need to be conscious of the needs of these people too as loneliness is a major health epidemic that should not be taken lightly. Attendance at Mosque is an important social connection, particularly for the elderly.

Infection control in Islam includes isolation and quarantine (2).  The Prophet instructed his followers not to travel to places known to be infected with a disease and advised those in contaminated areas or communities not to leave to avoid spreading it elsewhere (8) . After the Emmaus epidemic, the Muslim leader at the time, Amr ibn al-Aas, warned the people that the disease would spread like wildfire and directed them to protect themselves by escaping to the highest mountains. Moreover, he urged people to avoid contact with people with serious infectious diseases; the warning included contact with animals. In January 2020, China closed transit to and from Wuhan to contain the coronavirus outbreak. Recent epidemiological and human mobility data revealed that this ban diminished the spread of the epidemic from Wuhan to other cities in China. This delay in transmission allowed time to establish and reinforce other control measures necessary to help mitigate the epidemic (9).

Inaccurate information and the fear it generates have become more contagious than the virus itself, undermining public health advice and creating anxiety and stress. The twenty-first century ‘infomedia’ ecosystems quickly went viral with accusation of conspiracy theories, coupled with fear, racism and mass buying of items and even exploiting the crises for profit. Religion can play an important role in reminding people of the importance of verifying truth.  As well documented in the narration of hadith, Islam forbids lying, and people of faith should take a very careful approach to circulating knowledge and ensuring its accuracy. Therefore, Muslims must receive information carefully, verifying its authenticity before deciding whether there is benefit in transmitting it. In the Holy Quran, we find that God harshly criticises those who spread rumours and false information.

As the coronavirus continues to spread throughout the world, religious leaders have changed practices and adjusted services. Across the world, religious leaders have worked with public health experts to provide advice on how to mitigate the risk of gathering in faith settings such as mosques, churches, temples and synagogues and maximise the benefits of faith to aide efforts to mitigate COVID-19. 

Of special concern to Muslims is Umrah, the pilgrimage to Mecca in Saudi Arabia. Many Muslims from many countries around the world visit Mecca. The Kingdom of Saudi Arabia received 7.2 million pilgrims in 2019. The administration responsible for managing the two holy mosques in Mecca and Medina took proactive measures before the epidemic turned into a global pandemic. The Kingdom issued unprecedented order to close the two holy mosques, temporarily suspend visits and completely emptied the squares of prayers and visitors. This temporarily stopped visitors from coming to the Kingdom to visit the holiest of Islamic sites through pilgrimages that can be taken at any time of the year (10). This was a courageous and correct decision both from a public health and safely perspective but also from Islamic history. Similar steps were taken rapidly in Iran around the pilgrimage to Qom but at this stage Iran had already had significant community spread and the intervention was sadly too late. 

Other important steps followed. The Supreme Authority for Fatwa in the Kingdom of Saudi Arabia and other Islamic countries and organisations such as Al-Azhar Mosque in Egypt issued directives to prevent infected people from entering places of worship, insisting that they worship only in their homes. The ministries of Islamic affairs and mosques throughout the Islamic world and secular countries have also issued directives to cancel lectures and meetings and to limit the Friday sermons to online. Most significantly and importantly, Saudi Arabia pre-warned the Muslim world not to make financial commitment or concrete plans for Hajj 2020. It is highly probable that Hajj 2020 will be restricted to only those who live near to the holy Kaaba and only those who have been certified to be negative to SARS-CoV-2 will perform Hajj. Imams of mosques were further instructed to educate the people during their online Friday sermons about procedures and practices they should follow due to this crisis.

Likewise, the Director of Public Health of Qatar acted early and decisively and closed all public gatherings including religious activities. Qatar had less than 7000 Covid-19 cases and just nine deaths indicating one of the best survival rates for this disease. Absolute numbers for morality rate for Covid-19 are misleading. When we look at deaths per million population. Middle East countries including Israel and Turkey are below 30 deaths per one million population and Qatar and Saudi Arabia are three deaths per million population. In Birmingham, the Director of Public Health was invited early in the United Kingdom outbreak by Imams at major mosques across the city to speak at Friday prayers about the current situation and advice to the congregation, this reflects the important opportunity for faith and science to walk together.

Ramadan is fast approaching and will be a challenge for the Islamic countries and cities like Birmingham, London and Bradford. Scientists and scholars must engage with religious leaders and governments to provide reasonable and logical guidance for the faith followers while this pandemic continues. The Holy Quran values logic and reason “Surely, We have revealed it that you may understand.”

Conclusion

Although the focus has been largely on Islam in this opinion piece, many of the practices and opportunities are similar across multiple faiths. It is clear that public health must consider religion in the response to Covid-19 both to draw on these opportunities and recognise the potential risks. Across all religions and beliefs there must be an emphasis on reason, compassion and science alongside faith, so that we can work together to overcome the challenges ahead. We are not the masters of the earth but custodians and guest of it as illustrated by the poem produced for this article illustrates.

References

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2.         Salih NKM, Yusoff WMW. MICROBE IN MUSLIM SCHOLARS THINKING. RESEARCH JOURNAL (IUKLRJ).39.

3.         Besharat MA, Hosseini SA, Jahed HA, Ehsan HB, Dortaj F. Introduce a New Intervention Model Based on Islamic Lifestyle for Decreasing the Risk of Cardiovascular Disease in People at Risk: A Comparative Study. Journal of Religion and Health. 2020:1-16.

4.         Bhat AM, Qureshi AA. Significance of personal hygiene from Islamic perspective. Journal of Humanities and Social Science. 2013;10(5):35-9.

5.         Ng WK, Shaban RZ, van de Mortel T. Hand hygiene beliefs and behaviours about alcohol-based hand rub use: Questionnaire development, piloting and validation. Infection, disease & health. 2020;25(1):43-9.

6.         ibn Al-Hajjaj M, al-Husain A. Sahih Muslim. Dar al-Jail, Beirut, tt, Juz VI. 2007:223.

7.         al-Tirmidhi AI. al-Jamial-Sahih. Egypt, Mustafa al-Babi al-Halabi. 1976:2745.

8.         Al-Bukhari MII. The translation of the meanings of Sahih Al-Bukhari: Kazi Publications; 1986.

9.         Chinazzi M, Davis JT, Ajelli M, Gioannini C, Litvinova M, Merler S, et al. The effect of travel restrictions on the spread of the 2019 novel coronavirus (COVID-19) outbreak. Science. 2020.

10.       Ebrahim SH, Memish ZA. COVID-19: preparing for superspreader potential among Umrah pilgrims to Saudi Arabia. The Lancet. 2020;395(10227):e48.

 [1] Allegranzi B. et al. Religion and culture: Potential undercurrents influencing hand hygiene promotion in health care Am J Infect Contr, 37 (28) (2009), p. 34

Authors

Many thanks to the authors:

Faisal A. Alzahrani (1,4), Justin Varney (2), Asif Ahmed (3,4)

1Department of Biochemistry, Faculty of Science, Embryonic Stem Cell Unit, King Fahad Center for Medical Research, King Abdulaziz University, Jeddah 21589, Saudi Arabia. 2Department Public Health, Birmingham City Council, Birmingham, UK. 3Aston Medical Research Institute, Aston Medical School, Aston University, UK. 4MirZyme Therapeutics, Birmingham Innovation, Birmingham, B7 4BB, UK