The Muslim Mosaic
One in five human beings is a follower of Islam. Globe-spanning and fast-growing, the religion has natural but sometimes complicated ties to public health.
In the summer of 2003, an ancient enemy of humanity was almost defeated.
A 15-year international vaccination campaign was on the verge of eradicating poliomyelitis. Polio cases had been reduced from 350,000 worldwide in 1988 to just 784. Then, Muslim clerics in the northern Nigerian state of Kano urged a boycott of the U.S.-sponsored polio vaccine, claiming that it was part of an American plot to make Nigerian girls infertile. The Kano state government and two others stopped the vaccination campaign. The poliovirus spread.
By August 2004, polio cases in the region were five times higher than in the previous year, according to the World Health Organization. The resurgent virus spilled into Chad, Sudan and 10 other African countries. After an international Islamic conference endorsed polio vaccinations and after Nigerian officials visited vaccine factories in predominately Muslim Indonesia, the campaign was revived in mid-2004. But the damage was done. Polio cases worldwide increased to 1,263 by last year.
That’s one story from the intersection of Islam and public health. But here is another.In September 2004, Iraq was a war zone. U.S. jets, helicopters and tanks pounded insurgent positions in Mosul and Falluja as a wave of kidnappings and suicide car bombings engulfed Baghdad and other cities. To estimate civilian mortality in the wake of the March 2003 invasion by U.S. and coalition forces, Les Roberts and Iraqi researcher Riyadh Lafta randomly selected 33 “clusters” of 30 households each. Their study would provide the most reliable gauge of the invasion’s civilian consequences. Roberts, an associate with the Bloomberg School’s Center for Refugee and Disaster Response, and Lafta, a colleague from Al-Mustansiriya University in Baghdad, would ultimately estimate that about 100,000 Iraqis had been killed in Iraq since the U.S.-led invasion.
The estimate was shocking but it didn’t even include data from the 33rd cluster, the embattled city of Falluja. With data collected from 32 of 33 sites by mid-September, Roberts wanted to stop the study and spare Iraqi interviewers from going into Falluja. He thought the insurgent stronghold was too dangerous. Roberts pleaded with his Muslim friend Lafta not to go. He recalls Lafta’s reply: “God has picked these clusters. If God wants me, he will take me. I must go.”
Lafta and one interviewer went to Falluja on September 20. They survived and found that of the 33 neighborhoods studied, two-thirds of the recorded violent deaths had occurred in the Falluja cluster. The death toll there was so high that the researchers treated it separately for fear of skewing the study’s results.
A veteran of public health work in 30 countries and eight war zones, Roberts was stunned both by Lafta’s commitment and how he incorporated his religious beliefs into his scientific endeavors. “I can’t imagine anyone at Johns Hopkins willing to go to Falluja last September with the knowledge that God wants them to go. I know no one [who] perceives themselves so humbly to be a tool of God’s destiny,” says Roberts. “He sees his science as synonymous with service to God.”
The stories from Kano and Falluja are certainly not the first nor the last to emerge from the complex confluence of Islam and public health. Almost one in five people in the world is a Muslim, a fact that has huge implications for public health from Rabat to Jakarta, London to Karachi and most points in between. The umma, or Muslim community, links Muslims worldwide in a manner that is unparalleled in other religions. To ignore Islam and its role in a community invites failure for any public health program, whether it be polio eradication, HIV prevention or tobacco control. And yet to assume Islam explains everything about a given people is also wrong: Think of the social and economic differences between Morocco and Malaysia, or Somalia and Iran.
As PhD student Maliha Ilias says, “The only commonality between all Muslims is that they’re all different.”
In a world torn by sweeping economic changes, cataclysmic disparities in health, terrorism and a media-hyped “clash of civilizations” that supposedly pits Western modernity against Muslim values, public health may offer much-needed common ground. Yet public health’s many-faceted approach—science and society, individual and population, researcher and subjects—meets an immense challenge in the world’s 1.2 billion Muslims. How does Islam affect public health? Where does the influence of religion stop and cultural traditions begin? How does public health research adapt to Muslim countries?
For the faculty, students and alumni of the Bloomberg School, there are no simple answers just lessons learned from personal experience.
In some ways, it’s difficult to conceive of a more public health-friendly religion than Islam. The Quran and the hadith (teachings and sayings of the Prophet Muhammad) offer numerous directives about maintaining health at the community, family and individual levels. “Islam advocates aggressively for healthy behavior,” says Alfred Yassa, regional director for the Near East and Eastern Europe/Eurasia division for the Center for Communication Programs (CCP). “We are always able to quote verses from the Quran and from Islamic teachings that support healthy behavior.” From the Islamic perspective, God entrusts the human body to the individual, and it is the individual’s responsibility to keep it healthy. A CCP slogan that resonates with Muslim audiences was recently adopted by the Jordanian Ministry of Health for all of its materials: Our health is our responsibility. “People see that in tandem with Islamic teachings they hear every Friday in the mosque,” says Yassa, MD, MPH.
Islam’s public health inclinations as well as scientific advances and sporadic economic development helped ensure that Muslim countries benefited from the 20th century’s gains in public health. For example, Indonesia (the world’s most populous Muslim nation) reduced the mortality rate for children less than 5 years old from 216 per 1,000 in 1960 to 41 in 2003, according to United Nations data. During the same period, Saudi Arabia’s under-5 mortality rate dropped from 250 to 26. And the United Arab Emirates’ under-5 mortality rate of 8 equals the United States’. Life expectancy, another key indicator, has improved as well: in Bangladesh, it rose from 44 years to 62 years in the last three decades. And in Arab countries, life expectancy has increased by 15 years since the early 1970s, while infant mortality rates plummeted by two-thirds.
Yet inconsistent economic development, poor government and a lack of public health infrastructure have conspired to limit improvements in health in much of the Muslim world. The combined gross domestic product (GDP) of the Arab League’s 22 countries, for example, is $531 billion—about $65 billion less than the GDP of Spain alone, according to a United Nations Development Program report. And many Arab economies are hobbled by the small percentage of women who work. A June 2004 article in The Economist noted that just 6 percent of Saudi Arabia’s workforce is female and just one-third of Arab women have jobs. A 2002 article in the same magazine framed the consequences this way: “How can a society prosper when it stifles more than half its productive potential?” The result of such troubled economic prospects: With few exceptions, Muslim countries still lag far behind industrialized countries’ health indices. Compare Algeria and Bangladesh’s under-5 mortality rates (41 and 69 per 1,000, respectively) with industrialized countries’ average rate of 6. And life expectancy for a child born in Somalia today is 48 years. In Egypt, it is 69 years. But children born today in industrialized countries will live an average of 78 years.
In the past, some Muslim countries have been slow to confront public health issues such as overpopulation and HIV/AIDS because reproductive health topics are not easily broached in the conservative cultures found in nations like Saudi Arabia and Afghanistan. A Bloomberg School student from Iran recalls being told by a professor that it wasn’t “proper” for an Islamic country to have an AIDS problem. (Iran has since made AIDS prevention a high priority.) And, in the past, Western-financed family planning programs in some Middle Eastern countries have been resisted by those who believe the programs are part of a conspiracy to limit the Muslim population and “save room” for Israel.
However, demographer Ken Hill, professor of Population and Family Health Sciences, says there isn’t any real evidence that Islam is a barrier to public health or family planning initiatives. “You see resistance to family planning in conservative religious families in the U.S. And traditional families in Africa are resistant to adopting change,” says Hill, PhD. “I think it is a mistake to ascribe it to Islam.”
In fact, Islam not only advocates strongly for health but for advancing the science that improves and preserves health. “Islam says Allah has created a cure for every illness. It’s up to people to discover the cure,” says Saade Abdallah, an associate at the Center for Refugee and Disaster Response. “That is what we believe.”
Heaven lieth at the feet of mothers. —The Prophet Muhammad
Some wore veils, others simply wove flowers into their hair, but all the women wore white wedding dresses.
The men, like grooms the world over, wore dark suits and ties.
Nearly 150 newlywed couples from Minya, Egypt, paraded into the city’s stadium on September 9, 2004, on tractor-drawn carriages called tuf-tufs as 9,000 relatives and guests watched. There, Egyptian television celebrity Tarek Allam served as emcee for the evening, pop stars Essam Karika and Gawahar entertained them, and a six-tiered wedding cake festooned with flowers and ignited sparklers awaited. The newlywed celebration marked the launch of a USAID-financed family health campaign in Egypt led by CCP and other organizations. The campaign’s slogan is “Sahatek, Sarwatek” (Your Health, Your Wealth). As part of the evening’s entertainment, the newlywed couples competed for washing machines by answering questions like “How tall is your husband?” and “How long should you wait between pregnancies?”
Despite the country’s significant advances in public health, Egypt still has high rates of infant mortality (more than seven times the rate of industrialized countries) and maternal mortality (more than six times higher). And Egypt, like other countries whose economies are developing, is in the midst of an “epidemiological transition,” as the burden of infectious diseases like malaria decrease and chronic diseases like hypertension and diabetes increase. The situation demands a broad-based public health strategy.
The wedding celebration in Minya (which followed the newlyweds’ own marriage ceremonies) seemed the best way of starting a nationwide project, says Amrita Gill-Bailey, MA, a program officer at CCP. “The wedding is one of the most momentous events in life in Egypt. People spend a fortune on wedding celebrations,” she says. “There are 575,000 marriages each year in Egypt. It’s an entry point that the family health message could be given to people. This is something that culturally was really appropriate.”
The program is based on the premise that “households produce health.” It targets people at different stages of life: children, youth, older couples and young couples. For newlyweds, it educates them—before they start a family—about nutrition, hygiene, healthy lifestyles, antenatal and postpartum care, birth spacing and other issues. To communicate this, Gill-Bailey and her team wanted not only a splashy PR event (which was covered widely in the national media and on Al-Jazeera) but a message that would resonate with young Egyptians.
The program had a special component during Ramadan, Islam’s holy month that celebrates when Muhammad first received his divine revelations. Project organizers arranged for a special segment on a television variety show Al Afdal (The Best) that is widely watched during Ramadan. The host Tarek Allam sprinkled in public health advice during sometimes-teasing interviews with newlyweds. The message reached a large audience: During the month-long show, more than 1 million viewers called in to win prizes and a chance to be on the show.
“I think if you really want to have an impact, you have to be sure you are sensitive to the religious norms and cultural attitudes,” says Gill-Bailey. “You work with all parties carefully not to offend people, but at the same time to move knowledge and information forward.”
Follow your Imams. —Sahih Muslim, Book 4, Number 0824
When CCP’s Carol Underwood and Alfred Yassa arrived in Jordan in 1996, family planning and reproductive health topped their agenda. The fertility rate (number of children the average woman will have) was still high: 5.4 in 1990. Though the rate had been falling in recent years, Jordan still had a spiraling population with accompanying demands on food, water, infrastructure, education and so on. And Jordan’s population still suffered high rates of neonatal mortality and maternal mortality. Yet before embarking on a communications campaign to reduce fertility and expand reproductive health, Yassa and Underwood, now a senior research associate at CCP, knew they first had to understand what Muslim religious leaders in Jordan thought about contraception and family planning. “In the literature before this, there was a sense that religious leaders were more conservative in family planning than the people,” says Underwood. But she suspected that the leaders and people would share the same beliefs.
The researchers began by meeting with the religious leaders. “You should know how to work with them—mainly by ‘getting through the door and not the window,’ as they say. You go to the leadership to discuss the matter,” says Yassa. “They have a hierarchy. They’re a very organized community. They obey orders. If you have them on your side, you have a strong proponent. If they’re on the other side, you get nowhere.”
Underwood and Yassa planned to survey every religious leader in the country and then train them in family planning. Skeptics thought this would be impossible, but the pair pressed on anyway. Working with the Jordanian government’s Ministry of Islamic Affairs (which employs the vast majority of the country’s religious leaders), they surveyed 1,660 religious leaders about modern contraceptive methods, family planning (tanzim al-osra) and so on. The imams (who lead prayers on Fridays) and khatibs (who give the Friday sermons) were comfortable with traditional methods like withdrawal. But they did not know if modern methods like IUDs and injectible contraceptives were harmful to health or if they were sanctioned by Islam. A majority mistrusted the Pill, which some thought might cause long-term sterility, and condoms, which were associated with promiscuous sex.
With this information in hand, Yassa and his team designed a training program (conducted by religious leaders themselves). Better informed and more confident, the clerics talked about family planning much more often in their Friday sermons and when they met individually with people. Yassa believes the project played a key role in increasing the use of contraceptives in Jordan and reducing the country’s fertility rate. By 2003, it had fallen to 3.5.
This strategy is just one part of a successful public health campaign, says Saade Abdallah. “If you go through religious leaders, women will be under-represented,” says Abdallah, MBChB, MPH. “The religious leaders will take the message and deliver it at the mosque [but] most women don’t go to the mosque.” She remembers attending a recent workshop on HIV prevention in her native Kenya sponsored by a Muslim organization there. She was encouraged to see that 30 of the 130 attendees were women. (In previous workshops, there were only a few.) Women doctors, nurses, teachers and social workers attended, but a key constituency was missing: housewives. “It’s a challenge reaching women,” Abdallah says. “You have to have people going household to household to talk to groups of women.”
Leveraging the Sisterhood
PhD student Maliha Ilias is familiar with Western views of Muslim women and rejects many of them. Europeans and Americans see the burka or hijab (headscarf) and think oppression. Certain facts—that Saudi women cannot drive, travel without permission of a male guardian or expose their hair, wrists or ankles in public—stick in the Western consciousness. Other facts, just as true, seem not to resonate: More than half of Saudi Arabia’s university students are women; the veil is a personal choice for many; and Muslim women have led countries like Pakistan. Increasingly women work as business executives, high government officials and leaders of nongovernmental organizations and other groups.
Media reports frequently leave the impression that the lack of education and work opportunities for women is simply part of Islam, whereas the reasons are really cultural, says Ilias, who grew up in Oman and Pakistan. Islam, she notes, does not prescribe limits on education for women; rather, it secures the right of men and women to pursue the best education possible. The religion also reserves a special place for women as mothers. “Islam gives paramount importance and respect to mothers, even more than fathers,” says Ilias.
Yet religious and cultural traditions that require modesty for girls and women and keep them separate from those outside the family are often obstacles to health care and public health research. It’s a challenge that Gregg Greenough, deputy director of the Center for Refugee and Disaster Response, has often faced in his work improving the emergency health system in the West Bank and Gaza. If a woman arrives at a clinic or hospital with abdominal pain, a doctor needs to quickly decide if it is a surgical, obstetric or some other medical issue. “How do you effectively triage a woman who may be coming in with an ectopic pregnancy when you have [only] male staff there?” says Greenough, MD, MPH ’98, an emergency physician. “The examination of a woman is a big deal. A lot of times they have to call in a female obstetrician or midwife for those kinds of issues, which really delays care.”
The answer, of course, is to increase the number of women health professionals. But until that occurs, Gregory Pappas, an adjunct associate professor in International Health, says it’s still possible to do important and even revolutionary research on women’s health in Muslim countries. After a successful health survey in Pakistan that included women doctors performing physical exams on female study participants, Pappas led a study in another Muslim country, Uzbekistan. There, women doctors and nurses used vaginal swabs to test Uzbek women for Chlamydia, a curable sexually transmitted disease that can lead to infertility. The study found more than 10 percent of women had undiagnosed Chlamydia infections. “It was a major contribution to the public health of that country,” says Pappas, MD, PhD. “These cultural issues don’t have to be impediments when you understand the culture and you approach it with sensitivity and respect. I think a lot of times people approach Islam out of ignorance and there is all this worry about the politics of it, that you can’t deal with Muslims. Something about the Western thought process stops.”
Ilias recalls attending a lecture at the School by a prominent visiting scholar who said she could not find data about adolescent girls in Pakistan and their attitudes to sexual and reproductive health issues. “It’s not an issue of these girls [not having] things to say, but it’s about knowing how to speak to them without making them or their families uncomfortable,” says Ilias, who wears the hijab. At the lecture, a new career path dawned on her: She knew she could identify with the girls culturally and religiously.
At the Bloomberg School, to earn a doctorate in Population and Family Health Sciences, Ilias plans to educate adolescent females in Pakistan about family planning and reproductive health and to do research. “I’d like to give them knowledge not just about how their bodies work, but what the complications are if they don’t space out their births. I want [to help] them to think about themselves,” she says. What she hopes to achieve, Ilias says, is “in essence, growing better women so they can be better mothers as well.”
One unique and successful attempt to improve women’s health in Muslim countries is a CCP project called Arab Women Speak Out. Since 1999, more than 200,000 women have participated in the training program. The course includes group discussions and video documentaries that offer real-life examples of how Arab women have overcome patriarchal attitudes and social and economic obstacles to improve their lives and their communities. One profile highlights a 19-year-old Egyptian girl who opened a vegetable stall in the local market. She eventually earned enough money to bring electricity and running water to her family’s home. The program is not as controversial in Arab countries as it might appear because it emphasizes strengthening the family, not weakening the husband’s role, according to Carol Underwood. “It’s not a zero-sum game,” says Underwood, PhD. “If there is another potential breadwinner, another who can help with decision making, it strengthens the family,” she says. An empowered woman takes better care of herself and seeks better health care as well, says Underwood.
A Turnaround in Iran
Perhaps the West’s greatest misconception about Muslim countries is that they are stuck in the seventh century, ossified by tradition, endemic poverty, dictatorial governments and an inflexible religion. From a public health perspective at least, Iran, the world’s foremost Islamic theocracy, offers a strong counterexample.
Since even before the Islamic revolution in 1979, Iran has pursued a vigorous campaign to improve public health. According to UNICEF, Iran’s under-5 mortality rate dropped from 281 per 1,000 in 1960 to 39 in 2003. The fertility rate has been dramatically reduced from 7 to 2.3 during the same period. And life expectancy for a child born in 1970 was 54 years; today it is 70.
Farin Kamangar, an Epidemiology PhD candidate, lived through Iran’s public health successes, earning his MD and MPH at Tehran University and serving his two-year military service as a physician, often working on public health projects. “There is no question that in the first 5 or 10 years after the revolution the pace was very fast,” says Kamangar from his office at the National Institutes of Health, where he conducts epidemiological studies on esophageal cancer in Iran. “In the beginning of the revolution, everybody was like, ‘Let’s do good things.’ That is the beginning of every revolution, among the executions, of course.” Kamangar attributes much of the country’s success to efforts to create a basic rural health care system that puts a health center in each village. Two behvarz (health care workers) who have at least a ninth-grade education distribute contraceptives, perform primary health care and treat endemic diseases like malaria.
“I think it’s definitely a success story,” says CCP’s Underwood, who studied Iran’s health care system in the early 1990s and has ongoing projects there today. “They had the funds but also the political will. They put money into infrastructure and developed it so primary health care became available by the mid-1980s to 80 percent of the rural population.”
It remains to be seen how the invigorated Iranian health system will face new threats like HIV. There are an estimated 31,000 HIV-positive Iranians, representing a 0.1 percent adult prevalence rate, according to UN data. As in other Middle Eastern countries, Iran’s HIV epidemic is still in its infancy, says Homayoon Farzadegan, PhD, an Epidemiologyprofessor and director of the Human Retrovirus Research Laboratory. For the moment, it is mostly confined to injection drug users. But experience elsewhere predicts the epidemic’s deadly trajectory: It moves from injection drug users, to prostitutes and then to the general population. “The epidemic is very early and young in Iran, but it’s not going to stay like that,” says Farzadegan, who grew up in Iran. “It’s a wildfire. If it goes in, it takes. All you need is several thousand cases.”
Though condoms are manufactured in Iran and readily available, the government’s past attitude toward HIV prevention is best summed up in a pamphlet produced byIran's Center for Disease Control (cited in a 2002 New York Times article): “The best way to avoid AIDS is to be faithful to moral and family obligations and to avoid loose sexual relations. Trust in God in order to resist satanic temptations.” Like conservatives in Western countries, Iran’s ruling mullahs worried that open discussion of condoms in the media would signal their approval of promiscuous sex. But with a growing HIV threat, things are beginning to change. After securing a special license from the U.S. government (which has named Iran an embargoed country), Underwood began working with UNICEF and Iran’s Ministry of Health on a new HIV prevention campaign that targets adolescents. They are developing a series of booklets, which will include references to condoms. And discussion of condoms is beginning to creep into medical talk shows on the radio and television (though not on dramatic shows). But it’s a tentative, somewhat mysterious process. An Iranian colleague recently emailed Underwood: “As you know, in Iran nothing is black or white, everything is grayish!”
A sabbatical year in 1996 working on health care access issues among the Arab and Jewish populations in Israel convinced Farfel that public health is one way to bridge the bitter divisions in one of the world’s most conflicted areas. A Jewish-American researcher working in Arab villages, he was regarded as something of a novelty but was warmly received. He is now gearing up to return to Israel and bring with him a collaborative method of research that’s been proven to work in another difficult area of the world: East Baltimore.
Farfel has worked for 20 years with churches and other groups in East Baltimore’s African-American communities to devise ways to address the most pressing public health issues. “It’s a way to involve marginalized populations in improving their own quality of life,” he says. His strategy is known as commu-nity-based participatory research, and its goals are to involve community members in public health research and help them understand and apply the results. In Baltimore, for example, Farfel helped set up the Environmental Justice Community Partnership, which united residents and School faculty to educate the community about the hazards of lead paint and the urban demolitions of old housing in the area.
In northern Israel (where Arabs make up more than half the population), Farfel plans to link Israeli university colleagues with Arab village leaders, including the local imam and representatives from the town council, schools, businesses, health care providers and other groups. Together they will confront issues like the high prevalence of smoking among local men, child injuries, women’s health needs, access to health care and other issues. The project has a small planning grant from Israel’s Ministry of Health. “If we can get rolling with one village, that might be a model for other communities,” says Farfel. “I see it as part of the peace process. That’s what you want to do—bring people together and improve lives.”
The project is one step, but more dramatic, sustainable solutions are needed to effect positive change in Muslim countries in the future. Many say little can happen without economic development, the engine that makes it possible to build a robust education and public health infrastructure. This argument equates an increase in per capita income to an increase in health.
Others would argue that better education of women is the sine qua non of better health. In Mombassa or Zanzibar, Saade Abdallah says she frequently encounters less-educated mothers who are more likely to abandon breastfeeding, provide a poor diet for their children and have more children with less time between births. They typically agree to the man’s preference to avoid contraception, she says. “She has the right to say yes or no, but she is not aware of that,” Abdallah says during a brief stop in Baltimore between work assignments in Sudan and Afghanistan. Greater education for girls means increased opportunities as well. “Once she goes to school, she’s motivated maybe to go to high school,” says Abdallah. “But if she is at home where there is nothing else for her to do, she thinks it’s just marriage, that that’s her only option.”
Whatever drives change in Muslim countries, experts say the public health infrastructure needs certain improvements now, including an increased and sustained commitment to public health, better public health education that produces professionals to do locally based research, and a commitment to translate research into policies. In the view of Adnan Hyder, an assistant professor of International Health, these improvements would mean a greater percentage of the national budgets devoted to childhood immunization, vitamin A supplementation and pneumonia management; the education and support of a better trained public health workforce; strengthened community-based programs in health; improved health care facilities; and better-supported critical health research.
“If we can get good people, good scientists and a little bit more money in these countries, I’m very hopeful that public health will take off,” says Hyder, MBBS, PhD ’98, MPH ’93.
To accomplish the kind of extraordinary changes needed, the Muslim world needs a “paradigm shift” in attitudes, according to Hyder. “In Muslim countries, we have been talking about our peak—when Islamic astronomers and mathematicians and scientists actually discovered everything from numbers to basic chemistry and astronomy,” says Hyder. “Muslim countries now have to take hold of the future. They’ve got to move from a ‘we were there’ to a ‘how do we get there again?’ sort of philosophy. Frankly speaking, I think countries like the U.S. and institutions like Johns Hopkins can play a big role by training people from those countries and making sure they go back and share science and the latest discoveries.”
The result would be countries more reliant on their own public health research and locally driven interventions, rather than solutions provided by Western countries. As international health expert Gregory Pappas notes: “It shouldn’t be ‘safari science’ where you bag the big data and head home and put it on the mantle.”
With respect and common effort, Western and Muslim countries can make great improvements in public health, says Saade Abdallah. “There are a lot of things the West is trying to improve. They have to work with the people. You can’t just push them aside and say, ‘I’m here to do it,” says Abdallah. “Just build the capacity and work with them.”