By Lisa Perry-Gilkes, MD, FACS
With a Muslim population reported to be a quarter million and with 35 mosques in the metro area, Atlanta ranks as the city with the sixth largest Muslim population in the country. Cultural sensitivity in caring for the Muslim patients requires a basic understanding of Islam.
Islam, which in Arabic is derived from the word salam, or peace, is the second largest world religion with 1.57 billion Muslims worldwide. Encountering and caring for Muslim patients requires knowledge of and respect for cultural observances. Islam is based on five pillars:
1. Believing in Allah, Arabic for God, and Mohamed as his prophet (the last prophet in the lineage of prophets starting from Abraham).
3. Fasting during the holy month of Ramadan.
4. Contributing to charity.
5. Performing the hajj or the pilgrimage to Mecca at least once.
When caring for a Muslim patient, being sensitive to the traditions and cultural norms can go a long way to forming a strong patient-physician relationship.
1: Approach Alcohol and Smoking Topics Sensitively
Islam strictly forbids alcohol consumption, however it is still important to inquire about alcohol use in patients with suspected head and neck cancer. Be sure to approach this topic with sensitivity. It should not be assumed that not drinking is strictly observed, and it may not be admitted to in the presence of family members.
Smoking is not encouraged, but smoking of cigarettes or the hookah is common in Islamic countries. A common belief is that since the smoke is passed through water, the smoke is filtered and made harmless. However, this form of tobacco consumption may even be worse than cigarette smoke.
It’s important to ask about chewing tobacco when discussing substance use history. Betel nut (Areca catechu) chewing is common in certain cultures such as Yemen or the Indian subcontinent. This practice has been associated with oral cancer.
2: Know When Ramadan Occurs
Ramadan is the ninth month in the Muslim calendar. Ramadan lasts for 30 days and is based on the Islamic lunar calendar, which is 10 to 12 days shorter than the solar calendar and starts at sunset. (In 2018, Ramadan starts May 15 and last through June 14.)
During this period, observant Muslims refrain from taking anything by mouth from sunrise to sunset. The fast is broken at sunset and resumes at sunrise. Islamic dietary laws can be forgiven when the individual is ill, hospitalized and required to take medication and nourishment. Islamic dietary laws allow Muslims to modify the laws to save lives. During this period you may see an increased incidence of sialadentis and sialolithiasis.
3: Understand the Islamic Dietary Code
Like many religions, Islam has a set of dietary guidelines for its believers to follow. The strict dietary code includes only eating meat that is appropriately slaughtered, similar to kosher foods in Orthodox Judaism. It is interesting to know that all kosher food is acceptable as halal, which means lawful or permitted. Halal covers more than you would expect. The term is primarily associated with food, but it also covers products that include ingredients derived from animals, such as soap, cosmetics or medicine. Things that are haram, i.e. forbidden, are:
• Swine/pork and its by-products
• Animals improperly slaughtered or dead before slaughtering
• Animals killed in the name of anyone other than Allah (God)
• Alcohol and intoxicants
• Carnivorous animals, birds of prey and land animals without external ears (i.e. bugs, snakes and lizards)
• Blood and blood by-products
• Foods contaminated with any of the above products
4: Respect the Modesty of your Muslim Patients
Modesty is one of the requirements of Islam. You may be familiar with the head covering known as the hijab. This garment, most commonly seen outside of Muslim countries, covers the head and neck with the face uncovered. Although seen in more devout members, it may cover from ankle to lower face.
It is also suggested that men are required to cover from navel to the knee, and some will wear a small head covering, called a kufi. Female patients may wear their head covering during hospitalization. A knock on the door before entering the room would give the patient a chance to cover her head.
Muslim patients will feel more comfortable with care practitioners of the same sex. At registration, the office staff should ask the patient if she is comfortable being seen by a male physician. Another way to make the patient more comfortable with a male physician is to include a female chaperone in the room, especially during a physical exam. Male patients may not feel comfortable with a female practitioner with the personal history and more commonly with the physical exam.
5: Let Your Muslim Patients Take the Lead With Shaking Hands
Some female patients will not shake hands with a male practitioner. Therefore, it is important to ask before offering a handshake, “Do you feel comfortable shaking hands?” This advice also holds true for a female physician with a male Muslim patient. Eye contact is also commonly avoided, especially in mixed-gender situations.
Accommodate Islamic Traditions About Hospitalization and End of Life
When hospital admission is required, accommodations should be made for daily prayers. This could mean a specific prayer room or making room in their hospital room. It is important for Muslims to face Mecca during prayer. For the bedridden patients who cannot fully prostrate themselves, it would show a great sign of respect to position the bed to face Mecca, which is southeast in the U.S.
Death and its preparation are very important parts of the Islamic life cycle. It is customary to perform special prays for the patient. In the case that the family members are not able to attend the hospitalized patient, the Imam (the worship leader of a mosque, similar to a priest or rabbi) should be notified of the patient’s condition to counsel and console the patient.
After death, traditionally the family and/or friends wash the body to prepare it for burial, which will occur as soon as possible. Embalming should be avoided unless required by civil law, and cremation is not allowed by Islamic law.
Atlanta has a very diverse population. We need to keep in mind that our Muslim community is not homogeneous. Our Muslim patients come from diverse and varied backgrounds, from the Indian subcontinent to those born in the United States.
Keeping this in mind, we should avoid stereotypes and assumptions. With all patients, the care should be crafted to fit the individual. Using a culturally sensitive approach to all of our patients is a best practice with improved, welldeserved, better outcomes.